Individual
SON P LE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
409 W OAK ST, CARBONDALE, IL 62901-1464
(618) 529-4455
(618) 351-1287
Mailing address
PO BOX 3988, CARBONDALE, IL 62902-3988
(618) 457-5200
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
036106903
IL
207RI0011X
Interventional Cardiology Physician
Primary
036106903
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036106903
—
IL
01
—
060068152
RAILROAD
IL
Enumeration date
10/19/2006
Last updated
12/04/2024
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