Healthcare Provider Details

I. General information

NPI: 1568619088
Provider Name (Legal Business Name): MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 06/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S. MAIN ST.
DIETERICH IL
62424
US

IV. Provider business mailing address

1207 NETWORK CENTRE DR SUITE 3
EFFINGHAM IL
62401-4632
US

V. Phone/Fax

Practice location:
  • Phone: 217-925-5730
  • Fax: 217-925-5736
Mailing address:
  • Phone: 217-347-2707
  • Fax: 217-347-2827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number036120332
License Number StateIL

VIII. Authorized Official

Name: DR. EUGENE P. DUST
Title or Position: PRESIDENT OF MID-ILLINOIS MEDICAL C
Credential: M.D.
Phone: 217-347-2707