Basic Information
| Provider Information | |||||||||
| NPI: | 1265819379 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HSHS MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3215 EXECUTIVE PARK DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627034514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175235406 | ||||||||
| FaxNumber: | 2174929643 | ||||||||
| Practice Location | |||||||||
| Address1: | 3631 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627034777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175353685 | ||||||||
| FaxNumber: | 2175467889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2015 | ||||||||
| LastUpdateDate: | 04/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2175235406 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.