Organization
FAMILY MEDICAL CLINIC PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACQUELINE MUDD (AUTHORIZED OFFICIAL)
(217) 324-1100
Entity
Organization
Contact information
Practice address
1480 N GREEN MOUNT RD SUITE 200, O FALLON, IL 62269-3466
(618) 622-3450
(618) 622-3468
Mailing address
PO BOX 483, LITCHFIELD, IL 62056-0483
(217) 324-1100
(217) 324-1103
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DZ1647
RAILROAD MEDICARE PTAN
IL
Enumeration date
02/20/2019
Last updated
07/02/2020
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