Basic Information
| Provider Information | |||||||||
| NPI: | 1528266608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTOPHER GREATER AREA RURAL HEALTH PLANNING CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEST FRANKFORT COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 155 | ||||||||
| Address2: | RCA CLINIC | ||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189242401 | ||||||||
| FaxNumber: | 6187242571 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 WEST ST LOUIS STREET | ||||||||
| Address2: | WEST FRANKFORT COMMUNITY HEALTH CENTER | ||||||||
| City: | WEST FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189376409 | ||||||||
| FaxNumber: | 6189371619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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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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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 617270 | 01 | IL | MEDICARE | OTHER |