Basic Information
| Provider Information | |||||||||
| NPI: | 1255916078 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPRINGFIELD CLINIC LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19284 | ||||||||
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| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 MAIN ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616062036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094950200 | ||||||||
| FaxNumber: | 3096766545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2021 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | COUSINS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, MANAGED CARE & ANCILLARY SERVIC | ||||||||
| AuthorizedOfficialTelephone: | 2175287541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPRINFIELD CLINIC LLP | ||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.