Basic Information
| Provider Information | |||||||||
| NPI: | 1710159686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROGRESSIVE FAMILY CARE LTD. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 208 N MAIN ST | ||||||||
| Address2: | SUITE H | ||||||||
| City: | COLUMBIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622361756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182812273 | ||||||||
| FaxNumber: | 6182810245 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 N MAIN ST | ||||||||
| Address2: | SUITE H | ||||||||
| City: | COLUMBIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622361756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182812273 | ||||||||
| FaxNumber: | 6182810245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2008 | ||||||||
| LastUpdateDate: | 10/31/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIRK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | NELS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6182812273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROGRESSIVE FAMILY CARE LTD | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
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 | DG3299 | 01 | MEDICARE RR | OTHER |