Basic Information
Provider Information | |||||||||
NPI: | 1265419261 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HARRISBURG FAMILY PRACTICE LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRIMARY CARE GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 117 E CLARK ST | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | IL | ||||||||
PostalCode: | 629462702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182528625 | ||||||||
FaxNumber: | 6182522540 | ||||||||
Practice Location | |||||||||
Address1: | 117 E CLARK ST | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | IL | ||||||||
PostalCode: | 629462702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182528625 | ||||||||
FaxNumber: | 6182522540 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2005 | ||||||||
LastUpdateDate: | 09/22/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOATRIGHT | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 6182528625 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036042756 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.