Healthcare Provider Details

I. General information

NPI: 1598777435
Provider Name (Legal Business Name): CARE FIRST MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 BROADWAY ST STE 140
MOUNT VERNON IL
62864-2347
US

IV. Provider business mailing address

3307 BROADWAY ST STE 140
MOUNT VERNON IL
62864-2347
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-7200
  • Fax: 618-244-7274
Mailing address:
  • Phone: 618-244-7200
  • Fax: 618-244-7274

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 Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: VEENA K GUPTA
Title or Position: CEO
Credential: M.D.
Phone: 618-244-7200