# PASSAVANT PHYSICIAN ASSOCIATION

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

## Provider details

- **NPI number:** 1962689307
- **Authorized official:** MRS. WENDI D GRAHAM (PRACTICE PLAN ADMINISTRATOR)
- **Authorized official phone:** (217) 479-5663

## Contact information

- **Practice address:** 1600 W WALNUT ST, JACKSONVILLE, IL 62650-1136
- **Practice address phone:** (217) 479-5890
- **Practice address fax:** (217) 243-2206
- **Mailing address:** 1600 W WALNUT ST, JACKSONVILLE, IL 62650-1136
- **Mailing address phone:** (217) 479-5890
- **Mailing address fax:** (217) 479-5677

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 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 | — | NULL | Yes |
| 363LA2200X | Adult Health Nurse Practitioner | — | NULL | — |
| 363LA2200X | Adult Health Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 01/29/2008
- **Last updated:** 03/21/2018