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1401 S State St Suite B Champaign IL 61820 | |
| (217) 721-5080 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Family Medicine |
| Location | 1401 S State St, Champaign, Illinois |
| Authorized Official Name and Position | Carrie Keenan (COO) |
| Authorized Official Contact | 2176371310 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 2403 Champaign IL 61825 Ph: (772) 559-5878 | 1401 S State St Suite B Champaign IL 61820 Ph: (217) 721-5080 |
| NPI Number | 1871208074 |
|---|---|
| Provider Enumeration Date | 01/23/2023 |
| Last Update Date | 07/22/2024 |
| Medicare PECOS PAC ID | 8921546060 |
|---|---|
| Medicare Enrollment ID | O20240820002146 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1871208074 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 208000000X | Pediatrics | (* (Not Available)) | Secondary |
| Provider Name | Simone R Hampton |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1033184247 PECOS PAC ID: 3173612090 Enrollment ID: I20071130000010 |
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