Basic Information
| Provider Information | |||||||||
| NPI: | 1528048105 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTOPHER GREATER AREA RURAL HEALTH PLANNING CORP | ||||||||
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| OtherOrganizationName: | CLAY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | CHRISTOPHER GREATER AREA RURAL HEALTH PLANNING CORP | ||||||||
| Address2: | PO BOX 155 | ||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187242401 | ||||||||
| FaxNumber: | 6187242571 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 KINNAMAN DR | ||||||||
| Address2: | |||||||||
| City: | FLORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628394204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186628386 | ||||||||
| FaxNumber: | 6186624338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | MITROKA | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 6187242401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.