Basic Information
| Provider Information | |||||||||
| NPI: | 1891034294 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINI MEDICAL ASSOCIATES, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 MAPLE SUMMIT RD | ||||||||
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| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184987518 | ||||||||
| FaxNumber: | 6186390385 | ||||||||
| Practice Location | |||||||||
| Address1: | 1440 W WALNUT ST | ||||||||
| Address2: | STE 2A | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173433543 | ||||||||
| FaxNumber: | 2173432323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2013 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | MCNEAR | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6184987518 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036103709 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4215006 | 01 | IL | BCBS OF IL | OTHER |