Basic Information
| Provider Information | |||||||||
| NPI: | 1366683252 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DR. GEORGE SALIBA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1207 NETWORK CENTRE DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624014632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173472707 | ||||||||
| FaxNumber: | 2173472827 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 S VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624481727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187833800 | ||||||||
| FaxNumber: | 6187835070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2009 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | DUST | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF MID-ILLINOIS MEDICAL C | ||||||||
| AuthorizedOfficialTelephone: | 2173472707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 036108589 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 036108589 | 05 | IL | MEDICAID |