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601 N Bruns Ln Springfield IL 62702-3596 | |
| (217) 544-2744 | |
| (217) 544-2746 |
| Full Name | |
|---|---|
| Speciality | Clinic/center |
| Location | 601 N Bruns Ln, Springfield, Illinois |
| Authorized Official Name and Position | Erika R Gonzalez (CREDENTIALING COORDINATOR) |
| Authorized Official Contact | 3125926892 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
17 N State St Ste 500 Chicago IL 60602-3384 Ph: (312) 592-6800 | 601 N Bruns Ln Springfield IL 62702-3596 Ph: (217) 544-2744 |
| NPI Number | 1922414846 |
|---|---|
| Provider Enumeration Date | 07/11/2014 |
| Last Update Date | 10/17/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922414846 | NPI | - | NPPES |
| 36170901001 | Medicaid | IL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
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