Healthcare Provider Details

I. General information

NPI: 1962689307
Provider Name (Legal Business Name): PASSAVANT PHYSICIAN ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W WALNUT ST
JACKSONVILLE IL
62650-1136
US

IV. Provider business mailing address

1600 W WALNUT ST
JACKSONVILLE IL
62650-1136
US

V. Phone/Fax

Practice location:
  • Phone: 217-479-5890
  • Fax: 217-243-2206
Mailing address:
  • Phone: 217-479-5890
  • Fax: 217-479-5677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number036048526
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036057937
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. WENDI D GRAHAM
Title or Position: PRACTICE PLAN ADMINISTRATOR
Credential:
Phone: 217-479-5663