Healthcare Provider Details

I. General information

NPI: 1679637789
Provider Name (Legal Business Name): CROSSROADS PHYSICIAN CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DOCTORS PARK RD SUITE C
MOUNT VERNON IL
62864-6251
US

IV. Provider business mailing address

1 DOCTORS PARK RD SUITE C
MOUNT VERNON IL
62864-6251
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-1397
  • Fax: 618-242-9002
Mailing address:
  • Phone: 618-242-1397
  • Fax: 618-242-9002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7626