Basic Information
| Provider Information | |||||||||
| NPI: | 1841237583 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVID P DAVIS MEDICINE, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CLARK COUNTY FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 890 RIDGELAWN RD | ||||||||
| Address2: | PO BOX 399 | ||||||||
| City: | MARTINSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624420399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173824191 | ||||||||
| FaxNumber: | 2173824248 | ||||||||
| Practice Location | |||||||||
| Address1: | 890 RIDGELAWN RD | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624420399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173824191 | ||||||||
| FaxNumber: | 2173824248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2173824191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 036086811 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 316704395 | 05 | IL | MEDICAID | 0004400750 | 01 | IL | AETNA | OTHER | 238297 | 01 | IL | HEALTHLINK | OTHER | 006686 | 01 | IL | HEALTH ALLIANCE | OTHER | 000000079566 | 01 | IN | ANTHEM | OTHER | 01225376 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |