Healthcare Provider Details

I. General information

NPI: 1891494738
Provider Name (Legal Business Name): COLLABORATIVE MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W WALNUT ST STE 6
JACKSONVILLE IL
62650-1157
US

IV. Provider business mailing address

1515 W WALNUT ST STE 6
JACKSONVILLE IL
62650-1157
US

V. Phone/Fax

Practice location:
  • Phone: 217-243-5313
  • Fax: 217-243-7608
Mailing address:
  • Phone: 217-243-5313
  • Fax: 217-243-7608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES M CASEY
Title or Position: OWNER
Credential: DC
Phone: 217-473-8265