Basic Information
| Provider Information | |||||||||
| NPI: | 1437277571 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SARAH BUSH LINCOLN HEALTH CENTER | ||||||||
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| OtherOrganizationName: | CHARLESTON FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 HEALTH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619389253 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 116 W BUCHANAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619202522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173457700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 07/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | PLUARD | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2172582513 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SARAH BUSH LINCOLN HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.