# FAMILY MEDICAL CLINIC PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1477019909
- **Authorized official:** JACQUELINE MUDD (AUTHORIZED OFFICIAL)
- **Authorized official phone:** (217) 324-1100

## Contact information

- **Practice address:** 1480 N GREEN MOUNT RD SUITE 200, O FALLON, IL 62269-3466
- **Practice address phone:** (618) 622-3450
- **Practice address fax:** (618) 622-3468
- **Mailing address:** PO BOX 483, LITCHFIELD, IL 62056-0483
- **Mailing address phone:** (217) 324-1100
- **Mailing address fax:** (217) 324-1103

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 207R00000X | Internal Medicine Physician | — | NULL | Yes |
| 207R00000X | Internal Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 02/20/2019
- **Last updated:** 07/02/2020