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1512 N Green Mount Rd Suite 200 O Fallon IL 62269-1953 | |
| (618) 624-1860 | |
| (618) 624-1863 |
| Full Name | |
|---|---|
| Speciality | Internal Medicine - Geriatric Medicine |
| Location | 1512 N Green Mount Rd, O Fallon, Illinois |
| Authorized Official Name and Position | Jerrie K Weith (BUSINESS ADVISOR) |
| Authorized Official Contact | 6187795508 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 968 O Fallon IL 62269-0968 Ph: (618) 624-1860 | 1512 N Green Mount Rd Suite 200 O Fallon IL 62269-1953 Ph: (618) 624-1860 |
| NPI Number | 1730190018 |
|---|---|
| Provider Enumeration Date | 08/11/2006 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1730190018 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207RG0300X | Internal Medicine - Geriatric Medicine | (* (Not Available)) | Primary |
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