Basic Information
| Provider Information | |||||||||
| NPI: | 1154719177 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPRINGFIELD CLINIC MACOMB LAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 S 6TH ST | ||||||||
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| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627032403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 505 E GRANT ST | ||||||||
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| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614553394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098331733 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2014 | ||||||||
| LastUpdateDate: | 07/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | NERONE | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2175287541 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPRINGFIELD CLINIC, LLP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 14D0702013 | IL | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 14D0702013 | 01 | IL | CLIA | OTHER |