Basic Information
| Provider Information | |||||||||
| NPI: | 1205387958 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PASSAVANT PHYSICIAN ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172438455 | ||||||||
| FaxNumber: | 2172437951 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172438455 | ||||||||
| FaxNumber: | 2172437951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2016 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2174795890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PASSAVANT MEMORIAL AREA HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.