Healthcare Provider Details

I. General information

NPI: 1720370778
Provider Name (Legal Business Name): PASSAVANT PHYSICIAN ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 N WESTGATE AVE
JACKSONVILLE IL
62650-1156
US

IV. Provider business mailing address

1600 W WALNUT ST
JACKSONVILLE IL
62650-1136
US

V. Phone/Fax

Practice location:
  • Phone: 217-243-5474
  • Fax:
Mailing address:
  • Phone: 217-245-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209004842
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036056832
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036091905
License Number StateIL

VIII. Authorized Official

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