Organization
MIDWEST REGIONAL NEONATOLOGY ASSOCIATES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. REBECCA G BOLEN CPC (OFFICE MANAGER)
(618) 549-8464
Entity
Organization
Contact information
Practice address
405 W JACKSON ST, CARBONDALE, IL 62901-1462
(618) 543-0721
(618) 457-4735
Mailing address
1809 W MAIN ST, #306, CARBONDALE, IL 62901-2123
(618) 549-8464
(618) 457-4735
Taxonomy
Speciality
Code
Description
License number
State
2080N0001X
Neonatal-Perinatal Medicine Physician
Primary
36112572IL
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03932033
BLUE CROSS BLUE SHEILD
IL
Enumeration date
12/12/2006
Last updated
08/22/2020
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