| Optimal Health Medicine Llc | |
|
1368 Dadrian Professional Park Godfrey IL 62035-1685 | |
| (618) 433-9701 | |
| (618) 433-9706 |
| Full Name | Optimal Health Medicine Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 1368 Dadrian Professional Park, Godfrey, Illinois |
| Authorized Official Name and Position | Jon Anthony Wagnon (PRESIDENT) |
| Authorized Official Contact | 6184339701 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Optimal Health Medicine Llc 1368 Dadrian Professional Park Godfrey IL 62035-1685 Ph: (618) 433-9701 | Optimal Health Medicine Llc 1368 Dadrian Professional Park Godfrey IL 62035-1685 Ph: (618) 433-9701 |
| NPI Number | 1316299332 |
|---|---|
| Provider Enumeration Date | 10/15/2012 |
| Last Update Date | 11/13/2012 |
| Medicare PECOS PAC ID | 1254583164 |
|---|---|
| Medicare Enrollment ID | O20121128000361 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1316299332 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 036120316 (Illinois) | Primary |
| Provider Name | Jon Anthony Wagnon |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1265623268 PECOS PAC ID: 0345300596 Enrollment ID: I20081118000860 |
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