Healthcare Provider Details

I. General information

NPI: 1508850520
Provider Name (Legal Business Name): CROSSROADS PHYSICIANS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 CROSSROADS PL SUITE 110
MOUNT VERNON IL
62864-6254
US

IV. Provider business mailing address

1573 MALLORY LN STE 100
BRENTWOOD TN
37027-2895
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-6710
  • Fax: 618-244-6779
Mailing address:
  • Phone: 152-221-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LAURA J FEY
Title or Position: SR. DIRECTOR PHYSICIAN REV CYCLE
Credential:
Phone: 615-221-3641