MEDICARE: FAMILY PHYSICIANS OF MADISON COUNTY LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	080021119	OTHER	IL	RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6015373	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1093711905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PHYSICIANS OF MADISON COUNTY LTD

Provider Business Mailing Address
First Line	:	3 JUNCTION DR W
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-2916
Country	:	US
Telephone Number	:	618-288-5088
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 JUNCTION DR W
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-2916
Country	:	US
Telephone Number	:	618-288-5088
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAYMOND K WEBER
Credential	:	M.D.
Telephone Number	:	618-288-5088

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	07/21/2022

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