1568619088 NPI number — MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC

Table of content: (NPI 1568619088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568619088 NPI number — MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568619088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1207 NETWORK CENTRE DR
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
EFFINGHAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62401-4632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-347-2707
Provider Business Mailing Address Fax Number:
217-347-2827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 S. MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DIETERICH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-925-5730
Provider Business Practice Location Address Fax Number:
217-925-5736
Provider Enumeration Date:
08/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DUST
Authorized Official First Name:
EUGENE
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
PRESIDENT OF MID-ILLINOIS MEDICAL C
Authorized Official Telephone Number:
217-347-2707

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  036120332 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036120332 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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