Healthcare Provider Details

I. General information

NPI: 1134470859
Provider Name (Legal Business Name): KING CITY PHYSICIAN COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4117 S WATER TOWER PL SUITE C
MOUNT VERNON IL
62864-6567
US

IV. Provider business mailing address

4117 S WATER TOWER PL SUITE C
MOUNT VERNON IL
62864-6567
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-0672
  • Fax: 618-242-0862
Mailing address:
  • Phone: 618-242-0672
  • Fax: 618-242-0862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StateNULL

VIII. Authorized Official

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