Healthcare Provider Details

I. General information

NPI: 1205387958
Provider Name (Legal Business Name): PASSAVANT PHYSICIAN ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
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: 217-243-8455
  • Fax: 217-243-7951
Mailing address:
  • Phone: 217-243-8455
  • Fax: 217-243-7951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. STEPHEN G LEE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 217-479-5890