Healthcare Provider Details

I. General information

NPI: 1801920889
Provider Name (Legal Business Name): FAMILY MEDICINE OF MCLEANSBORO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 S WASHINGTON ST
MCLEANSBORO IL
62859-1139
US

IV. Provider business mailing address

208 SOUTH 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 TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name: MICHAEL S DAVENPORT
Title or Position: MANAGER
Credential: FNP
Phone: 618-927-8714