Provider Demographics
NPI:1801907431
Name:LI, PAUL K (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:K
Last Name:LI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:3105 FIELDS SOUTH DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3743
Practice Address - Country:US
Practice Address - Phone:217-902-7527
Practice Address - Fax:217-902-7755
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI378212086S0122X
IN01065914A2086S0122X
IL036129123208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34055400Medicaid
IN200928690Medicaid
IN000000596754OtherANTHEM PROVIDER NUMBER
G81430Medicare UPIN
IN200928690Medicaid
ILIL3270626/208905634Medicare PIN
G81430Medicare UPIN