Basic Information
| Provider Information | |||||||||
| NPI: | 1790779874 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROSSROADS PHYSICIAN CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CROSSROADS INTERNAL MEDICINE #1 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4101 N WATER TOWER PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182444313 | ||||||||
| FaxNumber: | 6182449592 | ||||||||
| Practice Location | |||||||||
| Address1: | 4101 N WATER TOWER PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182444313 | ||||||||
| FaxNumber: | 6182449592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 6154657626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CROSSROADS PHYSICIAN CORP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.