Organization
SURGICAL SPECIALISTS OF CENTRAL ILLINOIS SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN JOSEPH WHITE MD (PRESIDENT)
(217) 428-6300
Entity
Organization
Contact information
Practice address
1750 E LAKE SHORE DR, STE 200, DECATUR, IL 62521-3809
(217) 428-6300
(217) 428-6322
Mailing address
1750 E LAKE SHORE DR, STE 200, DECATUR, IL 62521-3809
(217) 428-6300
(217) 428-6322
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
—
IL
2086S0129X
Vascular Surgery Physician
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CI8411
MEDICARE TRAVELERS
—
Enumeration date
11/17/2005
Last updated
11/23/2007
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