Basic Information
| Provider Information | |||||||||
| NPI: | 1477019909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY MEDICAL CLINIC PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 483 | ||||||||
| Address2: | |||||||||
| City: | LITCHFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620560483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173241100 | ||||||||
| FaxNumber: | 2173241103 | ||||||||
| Practice Location | |||||||||
| Address1: | 1480 N GREEN MOUNT RD SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622693466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186223450 | ||||||||
| FaxNumber: | 6186223468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2019 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | MUDD | ||||||||
| AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2173241100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | DZ1647 | 01 | IL | RAILROAD MEDICARE PTAN | OTHER |