Basic Information
Provider Information | |||||||||
NPI: | 1346784675 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASSOCIATED PHYSICIANS GROUP LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Mailing Information | |||||||||
Address1: | 916 TALON DR | ||||||||
Address2: | SUITE 102 | ||||||||
City: | O FALLON | ||||||||
State: | IL | ||||||||
PostalCode: | 622691848 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186288211 | ||||||||
FaxNumber: | 6186280883 | ||||||||
Practice Location | |||||||||
Address1: | 509 HAMACHER ST | ||||||||
Address2: | SUITE 202 | ||||||||
City: | WATERLOO | ||||||||
State: | IL | ||||||||
PostalCode: | 622981592 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189395979 | ||||||||
FaxNumber: | 6189395984 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2016 | ||||||||
LastUpdateDate: | 12/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARSON | ||||||||
AuthorizedOfficialFirstName: | RENEE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 6186288211 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085.005551 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.