Healthcare Provider Details

I. General information

NPI: 1265419261
Provider Name (Legal Business Name): HARRISBURG FAMILY PRACTICE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E CLARK ST
HARRISBURG IL
62946-2702
US

IV. Provider business mailing address

117 E CLARK ST
HARRISBURG IL
62946-2702
US

V. Phone/Fax

Practice location:
  • Phone: 618-252-8625
  • Fax: 618-252-2540
Mailing address:
  • Phone: 618-252-8625
  • Fax: 618-252-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036042756
License Number StateIL

VIII. Authorized Official

Name: MICHELLE BOATRIGHT
Title or Position: ADMINISTRATOR
Credential:
Phone: 618-252-8625