Basic Information
| Provider Information | |||||||||
| NPI: | 1467587154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINI MEDICAL ASSOCIATES SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 MAPLE SUMMIT RD | ||||||||
| Address2: | |||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184987518 | ||||||||
| FaxNumber: | 6184983052 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | GIRARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626401547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176272141 | ||||||||
| FaxNumber: | 2176273635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | KRIBS | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6184987518 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4215006 | 01 | IL | BCBS OF ILLINOIS | OTHER |