Basic Information
| Provider Information | |||||||||
| NPI: | 1093810350 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEBER MEDICAL CLINIC LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N EAST ST | ||||||||
| Address2: | WEBER MEDICAL CLINIC LTD | ||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624502499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183955222 | ||||||||
| FaxNumber: | 6183958552 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N EAST ST | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624502499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183955222 | ||||||||
| FaxNumber: | 6183958552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 03/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6183952223 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | CL4973 | 01 | RAILROAD MEDICARE | OTHER | 08015410 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |