Healthcare Provider Details

I. General information

NPI: 1790172583
Provider Name (Legal Business Name): HSHS MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N PROMENADE ST
HAVANA IL
62644-1243
US

IV. Provider business mailing address

3215 EXECUTIVE PARK DR
SPRINGFIELD IL
62703-4514
US

V. Phone/Fax

Practice location:
  • Phone: 217-243-1101
  • Fax: 217-243-5003
Mailing address:
  • Phone: 217-523-5406
  • Fax: 217-492-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MELINDA CLARK
Title or Position: CEO
Credential: CEO
Phone: 217-523-5406