Healthcare Provider Details

I. General information

NPI: 1649421207
Provider Name (Legal Business Name): JACKSONVILLE PEDIATRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W WALNUT ST EAST WING, 3RD FLOOR
JACKSONVILLE IL
62650-1136
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-5437
  • Fax: 217-243-3113
Mailing address:
  • Phone: 800-577-5368
  • Fax: 217-757-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: J. TRAVIS DOWELL
Title or Position: VICE PRESIDENT, HCNA AND OPERATIONS
Credential:
Phone: 217-788-3342