Healthcare Provider Details

I. General information

NPI: 1366504888
Provider Name (Legal Business Name): CROSSROADS PHYSICIAN CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 S WASHINGTON STREET
MCLEANSBORO IL
62859
US

IV. Provider business mailing address

208 S WASHINGTON STREET
MCLEANSBORO IL
62859
US

V. Phone/Fax

Practice location:
  • Phone: 618-643-2835
  • Fax: 618-643-2891
Mailing address:
  • Phone: 618-643-2835
  • Fax: 618-643-2891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DEBBIE E BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 877-892-9813