Basic Information
| Provider Information | |||||||||
| NPI: | 1568619088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIETERICH COMMUNITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1207 NETWORK CENTRE DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624014632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173472707 | ||||||||
| FaxNumber: | 2173472827 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 S. MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | DIETERICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179255730 | ||||||||
| FaxNumber: | 2179255736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2008 | ||||||||
| LastUpdateDate: | 06/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | DUST | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF MID-ILLINOIS MEDICAL C | ||||||||
| AuthorizedOfficialTelephone: | 2173472707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 036120332 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 036120332 | 05 | IL | MEDICAID |