Basic Information
| Provider Information | |||||||||
| NPI: | 1548494818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS ASSOCIATES PSYCHIARY P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 790 | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620250790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186562000 | ||||||||
| FaxNumber: | 6186561169 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 W TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | VANDALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624711227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186562000 | ||||||||
| FaxNumber: | 6186561169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2009 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | STEVENS | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6186562000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ILLINOIS ASSOCIATES PSYCHIATRY P C | ||||||||
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| AuthorizedOfficialCredential: | CPC CCS-P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 060006403 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 060006403 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | 060006403 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.