Healthcare Provider Details

I. General information

NPI: 1750375770
Provider Name (Legal Business Name): CROSSROADS PHYSICIAN CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N MAIN ST SUITE A
BENTON IL
62812-1313
US

IV. Provider business mailing address

320 N MAIN ST SUITE A
BENTON IL
62812-1313
US

V. Phone/Fax

Practice location:
  • Phone: 618-439-6370
  • Fax: 618-439-6490
Mailing address:
  • Phone: 618-439-6370
  • Fax: 618-439-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7626