Basic Information
| Provider Information | |||||||||
| NPI: | 1629465414 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HSHS MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3051 HOLLIS DR FL 2 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627047452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174929695 | ||||||||
| FaxNumber: | 2174929643 | ||||||||
| Practice Location | |||||||||
| Address1: | 1745 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626506126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0053262798 | ||||||||
| FaxNumber: | 2172435003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2015 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WATSON | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2174925806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.