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Il Route 146 Bldg 2 Elizabethtown IL 62931 | |
(618) 285-6191 | |
(618) 285-6833 |
Full Name | |
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Speciality | Clinic/Center |
Location | Il Route 146 Bldg 2, Elizabethtown, Illinois |
Authorized Official Name and Position | Frederick L Bernstein (CEO) |
Authorized Official Contact | 6184570450 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Po Box 3008 Carbondale IL 62902-3008 Ph: (618) 457-0450 | Il Route 146 Bldg 2 Elizabethtown IL 62931 Ph: (618) 285-6191 |
NPI Number | 1568454130 |
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Provider Enumeration Date | 08/18/2005 |
Last Update Date | 09/01/2010 |
Medicare PECOS PAC ID | 0749194702 |
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Medicare Enrollment ID | O20070202000064 |
Identifier | Type | State | Issuer |
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1568454130 | NPI | - | NPPES |
1616948 | Other | IL | BLUE CROSS BLUE SHIELD |
Taxonomy | Type | License (State) | Status |
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261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |