Basic Information
| Provider Information | |||||||||
| NPI: | 1962428516 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHNSTON CITY MEDICAL CLINIC, S. C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W BROADWAY BLVD | ||||||||
| Address2: | P. O. BOX 209 | ||||||||
| City: | JOHNSTON CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629511427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189836911 | ||||||||
| FaxNumber: | 6189836913 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 W BROADWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629511427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189836911 | ||||||||
| FaxNumber: | 6189836913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JAVED | ||||||||
| AuthorizedOfficialFirstName: | KHALID | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6189836911 | ||||||||
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| 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 | 261QR1300X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.