Individual
REX STOMBAUGH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
1441 W BROADWAY, CENTRALIA, IL 62801-5613
(618) 532-9050
Mailing address
1441 W BROADWAY, CENTRALIA, IL 62801-5613
(618) 532-9050
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CE9335
RR GROUP NUMBER
IL
01
—
P00345215
RR MEDICARE NUMBER
IL
Enumeration date
06/15/2006
Last updated
11/27/2007
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