Basic Information
| Provider Information | |||||||||
| NPI: | 1952304412 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARSHALL CLINIC EFFINGHAM, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 N MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173424151 | ||||||||
| FaxNumber: | 2173424190 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173424151 | ||||||||
| FaxNumber: | 2173424190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | KNAUER | ||||||||
| AuthorizedOfficialFirstName: | HOPE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2173424151 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036095601 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207N00000X | 036099940 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 208000000X | 036089116 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | 036084841 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 036108589 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 036103305 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 036094764 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | 036112996 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 036089116 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036094764 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036103305 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | 036085448 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CK1050 | 01 | IL | RAILROAD MEDICARE | OTHER | 14D0902430 | 01 | IL | CLIA | OTHER | 2523659 | 01 | IL | BC/BS GROUP PROVIDER # | OTHER | 0881270001 | 01 | IL | DME MAC, MEDICARE | OTHER |