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NPI Code Detail

MEDICARE: HARRISBURG FAMILY PRACTICE LTD

MEDICARE: HARRISBURG FAMILY PRACTICE 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
1207Q00000XFamily Medicine Physician036042756IL

General Provider Information

NPI Number : 1265419261
Entity Type Code : Organization
Provider Name (Legal Business Name) : HARRISBURG FAMILY PRACTICE LTD
Provider Business Mailing Address
First Line : 117 E CLARK ST
Second Line :
City : HARRISBURG
State : IL
Zip : 62946-2702
Country : US
Telephone Number : 618-252-8625
Fax Number : 618-252-2540
Provider Business Practice Location Address
First Line : 117 E CLARK ST
Second Line :
City : HARRISBURG
State : IL
Zip : 62946-2702
Country : US
Telephone Number : 618-252-8625
Fax Number : 618-252-2540
Authorized Official
Title or Position : ADMINISTRATOR
Name : MICHELLE BOATRIGHT
Credential :
Telephone Number : 618-252-8625
Provider Enumeration Date : 12/30/2005
Last Update Date : 09/22/2011

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Directions to “HARRISBURG FAMILY PRACTICE LTD ” Practice Location

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