Basic Information
Provider Information | |||||||||
NPI: | 1003040387 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ILLINOIS ASSOCIATES PSYCHIATRY P C | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 790 | ||||||||
Address2: |   | ||||||||
City: | EDWARDSVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 620250790 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186562000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 817 N STANFORD RD | ||||||||
Address2: |   | ||||||||
City: | FLORA | ||||||||
State: | IL | ||||||||
PostalCode: | 628393243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186562000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/14/2009 | ||||||||
LastUpdateDate: | 03/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STEVENS | ||||||||
AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
AuthorizedOfficialMiddleName: | ANNE | ||||||||
AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6186562000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ILLINOIS ASSOCIATES PSYCHIATRY P C | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC CCS-P | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 060006403 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 060006403 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | 060006403 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.