Organization
15 PARK PLACE LLC
Active
Other names
Adult Internal Medicine Office Practice
Organization subpart
No
Provider details
NPI number
Authorized official
CLARA AMPADU FNPC (CEO)
(618) 580-1359
Entity
Organization
Contact information
Practice address
15 PARK PL STE 1, SWANSEA, IL 62226-2918
(618) 580-1359
(618) 234-7242
Mailing address
15 PARK PL STE 1, SWANSEA, IL 62226-2918
(618) 580-1359
(618) 234-7242
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
363LP2300X
Primary Care Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0360832704
—
IL
Enumeration date
04/22/2020
Last updated
07/08/2020
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