Basic Information
| Provider Information | |||||||||
| NPI: | 1750353454 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL ASSOCIATES OF JERSEYVILLE, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 364 | ||||||||
| Address2: | |||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620520364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184987108 | ||||||||
| FaxNumber: | 6184987919 | ||||||||
| Practice Location | |||||||||
| Address1: | 270 MAPLE SUMMIT RD | ||||||||
| Address2: | MCDOW BUILDING | ||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184987108 | ||||||||
| FaxNumber: | 6184987919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | BENWARE | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6184987108 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 042007207 | 01 | IL | CORPORATE LICENSE | OTHER |