Healthcare Provider Details

I. General information

NPI: 1366779282
Provider Name (Legal Business Name): PHYSICIANS GROUP ASSOCIATES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2009
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N MAIN ST
NEW BERLIN IL
62670-4593
US

IV. Provider business mailing address

PO BOX 500
CHATHAM IL
62629-0500
US

V. Phone/Fax

Practice location:
  • Phone: 217-488-2201
  • Fax: 217-488-3508
Mailing address:
  • Phone: 217-670-2424
  • Fax: 217-670-2809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036064159
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-003289
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES LAFATA
Title or Position: PRESIDENT
Credential:
Phone: 217-698-9722