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Organization
PASSAVANT PHYSICIAN ASSOCIATION
Active
Organization
PASSAVANT PHYSICIAN ASSOCIATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. WENDI D GRAHAM (PRACTICE PLAN ADMINISTRATOR)
(217) 479-5663
Entity
Organization
Contact information
Practice address
1600 W WALNUT ST, JACKSONVILLE, IL 62650-1136
(217) 479-5890
(217) 243-2206
Mailing address
1600 W WALNUT ST, JACKSONVILLE, IL 62650-1136
(217) 479-5890
(217) 479-5677
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
NULL
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
—
NULL
207R00000X
Internal Medicine Physician
—
—
207VX0000X
Obstetrics Physician
036048526
IL
207Y00000X
Otolaryngology Physician
036057937
IL
2083P0011X
Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
—
NULL
2083P0011X
Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
—
—
208600000X
Surgery Physician
—
NULL
208600000X
Surgery Physician
—
—
231H00000X
Audiologist
—
NULL
231H00000X
Audiologist
—
—
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
NULL
363LA2200X
Adult Health Nurse Practitioner
—
NULL
363LA2200X
Adult Health Nurse Practitioner
—
—
Other
Enumeration date
01/29/2008
Last updated
03/21/2018
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