Healthcare Provider Details

I. General information

NPI: 1407279623
Provider Name (Legal Business Name): ASSOCIATED PHYSICIANS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 TALON DR SUITE 102
O FALLON IL
62269-1848
US

IV. Provider business mailing address

916 TALON DR SUITE 102
O FALLON IL
62269-1848
US

V. Phone/Fax

Practice location:
  • Phone: 618-628-8211
  • Fax: 618-628-0883
Mailing address:
  • Phone: 618-628-8211
  • Fax: 618-628-0883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: BLAKE RANDLES
Title or Position: RAD TECH
Credential: DC
Phone: 618-628-8211