Healthcare Provider Details

I. General information

NPI: 1437176435
Provider Name (Legal Business Name): FAMILY FIRST PHYSICIANS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 PEARSON DR
GENOA IL
60135-1355
US

IV. Provider business mailing address

599 PEARSON DR
GENOA IL
60135-1355
US

V. Phone/Fax

Practice location:
  • Phone: 815-784-6300
  • Fax: 815-784-6363
Mailing address:
  • Phone: 815-784-6300
  • Fax: 815-784-6363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036114320
License Number StateIL

VIII. Authorized Official

Name: KAREN M FEDERICI
Title or Position: OWNER
Credential: MD
Phone: 815-784-6300