Healthcare Provider Details

I. General information

NPI: 1962428516
Provider Name (Legal Business Name): JOHNSTON CITY MEDICAL CLINIC, S. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W BROADWAY BLVD
JOHNSTON CITY IL
62951-1427
US

IV. Provider business mailing address

201 W BROADWAY BLVD P. O. BOX 209
JOHNSTON CITY IL
62951-1427
US

V. Phone/Fax

Practice location:
  • Phone: 618-983-6911
  • Fax: 618-983-6913
Mailing address:
  • Phone: 618-983-6911
  • Fax: 618-983-6913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. KHALID JAVED
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 618-983-6911