Basic Information
| Provider Information | |||||||||
| NPI: | 1770200461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MBH EAST MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 192 | ||||||||
| Address2: | |||||||||
| City: | DU QUOIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628320192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185422146 | ||||||||
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| Practice Location | |||||||||
| Address1: | 912 N WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | DU QUOIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628321232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185422146 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2022 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | CALDERON | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6185421005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARSHALL BROWNING HOSPITAL ASSOCIATION | ||||||||
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| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.