Individual
RENEE ALWAN PERCELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.-C.
Contact information
Practice address
1701 E COLLEGE AVE, BLOOMINGTON, IL 61704-2101
(309) 664-3000
(309) 664-3026
Mailing address
1701 E COLLEGE AVE, BLOOMINGTON, IL 61704-2101
(309) 664-3000
(309) 664-3026
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
3289
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
031813
MEDICARE
AZ
01
—
031814
MEDICARE
AZ
01
—
031815
MEDICARE
AZ
01
—
031820
MEDICARE
AZ
01
—
3289
LICENSE
AZ
01
—
IL2613
MEDICARE GROUP NUMBER
IL
Enumeration date
10/18/2005
Last updated
09/20/2010
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