Healthcare Provider Details

I. General information

NPI: 1265592455
Provider Name (Legal Business Name): JASON D CHURCHILL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 MAPLE ST
ELDORADO IL
62930-1662
US

IV. Provider business mailing address

510 LINCOLN DR
HERRIN IL
62948-6334
US

V. Phone/Fax

Practice location:
  • Phone: 618-273-3361
  • Fax: 618-273-2504
Mailing address:
  • Phone: 618-997-4310
  • Fax: 618-998-9635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2006030653
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-002808
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: