NPIMap

Organization Active NPI

Central Illinois Oral and Maxillofacial Surgery, PC

  • Oral and Maxillofacial Surgery (Dentist)
  • Effingham, IL
National Provider Identifier
1891843595
Registry record updated Jun 29, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
License
019-024942 Issued in IL
Legal business name
CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PC
Practice address
1200 Network Centre Dr
Suite B
Effingham, IL 62401-4637
Phone
(217) 540-5800
Fax
(217) 342-2557
NPI assigned
Jan 8, 2007
Organization subpart
Yes
Parent organization
CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 29, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amy Kroeger
Title
Ins Coodinator
Phone
(217) 540-5100

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist)Group: 193400000X SINGLE SPECIALTY GROUP 1223S0112X 019-024942 IL Primary

Addresses

Primary practice location

1200 Network Centre Dr
Suite B
Effingham, IL 62401-4637

Mailing address

1200 Network Centre Dr
Suite B
Effingham, IL 62401-4637
Phone (217) 540-5800

Other identifiers 1

IdentifierTypeStateIssuer
1014426MedicaidIL

Other names 1

  • Central Illinois Oral Surgery Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070116000497 IL Part B Supplier - Clinic/Group Practice 4486655529 Receives reassigned benefits from 1 practitioner
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Effingham, IL

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Central Illinois Oral Maxillofacial Surgery4 organizations share this tax ID, including this one
Part of
Central Illinois Oral Maxillofacial Surgery

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

100 Greenview Dr
#B
Effingham, IL 62401
Phone (217) 540-5348

1200 Network Centre Dr
Ste B
Effingham, IL 62401
Phone (217) 355-2809

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168214400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1687996800000",
    "number": "1891843595",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 NETWORK CENTRE DR",
            "address_2": "SUITE B",
            "city": "EFFINGHAM",
            "state": "IL",
            "postal_code": "624014637",
            "telephone_number": "217-540-5800",
            "fax_number": "217-342-2557"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1200 NETWORK CENTRE DR",
            "address_2": "SUITE B",
            "city": "EFFINGHAM",
            "state": "IL",
            "postal_code": "624014637",
            "telephone_number": "217-540-5800",
            "fax_number": "217-342-2557"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PC",
        "enumeration_date": "2007-01-08",
        "last_updated": "2023-06-29",
        "certification_date": "2023-06-29",
        "status": "A",
        "authorized_official_last_name": "KROEGER",
        "authorized_official_first_name": "AMY",
        "authorized_official_title_or_position": "INS COODINATOR",
        "authorized_official_telephone_number": "217-540-5100"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "IL",
            "license": "019-024942",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1014426",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Central Illinois Oral Surgery",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Central Illinois Oral Surgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Effingham, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 29, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.