Basic Information
| Provider Information | |||||||||
| NPI: | 1437301611 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSONVILLE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INTERNAL MEDICINE CLINIC OF JACKSONVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005775368 | ||||||||
| FaxNumber: | 2177572021 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 W LAFAYETTE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626503707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172451421 | ||||||||
| FaxNumber: | 2172431699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 10/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | DOWELL | ||||||||
| AuthorizedOfficialFirstName: | J. TRAVIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, HCNA AND OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2177883342 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.