Basic Information
| Provider Information | |||||||||
| NPI: | 1366930281 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPRINGFIELD CLINIC LLP | ||||||||
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| OtherOrganizationName: | SPRINGFIELD CLINIC ALTAMONT LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19248 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 DO IT DR | ||||||||
| Address2: | |||||||||
| City: | ALTAMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624111135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184836131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2018 | ||||||||
| LastUpdateDate: | 04/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | NERONE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2175287541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPRINGFIELD CLINIC LLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 14D0938195 | 01 | CLIA | OTHER |