Basic Information
| Provider Information | |||||||||
| NPI: | 1659679363 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS/INDIANA EM-I MEDICAL SERVICES, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80175 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191011175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003550808 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1314 E WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475012860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122542760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2011 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8007321066 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.