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Organization
PASSAVANT PHYSICIAN ASSOCIATION
Active
Organization
PASSAVANT PHYSICIAN ASSOCIATION
Active
Other names
Passavant Internal Medicine Rural Health Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
MR. STEPHEN G LEE (MANAGER)
(217) 479-5890
Entity
Organization
Contact information
Practice address
559 N WESTGATE AVE, JACKSONVILLE, IL 62650-1156
(217) 243-5474
Mailing address
1600 W WALNUT ST, JACKSONVILLE, IL 62650-1136
(217) 245-9541
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
036056832
IL
207R00000X
Internal Medicine Physician
Primary
036091905
IL
363LA2200X
Adult Health Nurse Practitioner
209004842
IL
Other
Enumeration date
05/10/2011
Last updated
07/06/2011
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