Primary Care Clinic Profile
Full Name | |
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Speciality | Clinic/Center |
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Location | 1900 State St, Chester, Illinois |
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Authorized Official Name and Position | Morgan Bendorf (CFO) |
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Authorized Official Contact | 6188264581 |
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Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address and Practice Location
Mailing Address | Practice Location Address |
1900 State St Chester IL 62233-1116 Ph: (618) 826-4581 | 1900 State St Chester IL 62233-1116 Ph: (618) 826-2388 |
NPI Details:
NPI Number | 1629469002 |
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Provider Enumeration Date | 02/06/2015 |
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Last Update Date | 10/11/2024 |
Medicare PECOS Information:
Medicare PECOS PAC ID | 5294649372 |
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Medicare Enrollment ID | O20150414000018 |
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Medical Identifiers
Medical identifiers for
such as npi, medicare ID, medicare PIN, medicaid, etc.
Identifier | Type | State | Issuer |
1629469002 | NPI | - | NPPES |
Medical Taxonomies and Licenses
Taxonomy | Type | License (State) | Status |
207Q00000X | Family Medicine | 036-051292 (Illinois) | Secondary |
207Q00000X | Family Medicine | 036-052369 (Illinois) | Secondary |
207Q00000X | Family Medicine | 036-130378 (Illinois) | Secondary |
207Q00000X | Family Medicine | 036-087561 (Illinois) | Secondary |
208600000X | Surgery | 036-127160 (Illinois) | Secondary |
208600000X | Surgery | 036-046019 (Illinois) | Secondary |
261QR1300X | Clinic/center - Rural Health | (* (Not Available)) | Primary |
282NC0060X | General Acute Care Hospital - Critical Access | 0001495 (Illinois) | Secondary |
363A00000X | Physician Assistant | 085-003568 (Illinois) | Secondary |
363A00000X | Physician Assistant | 085-003575 (Illinois) | Secondary |
363L00000X | Nurse Practitioner | 209-009681 (Illinois) | Secondary |
367500000X | Nurse Anesthetist, Certified Registered | 041-149926 (Illinois) | Secondary |
367500000X | Nurse Anesthetist, Certified Registered | 209-009387 (Illinois) | Secondary |
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