Healthcare Provider Details

I. General information

NPI: 1477019909
Provider Name (Legal Business Name): FAMILY MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 N GREEN MOUNT RD SUITE 200
O FALLON IL
62269-3466
US

IV. Provider business mailing address

PO BOX 483
LITCHFIELD IL
62056-0483
US

V. Phone/Fax

Practice location:
  • Phone: 618-622-3450
  • Fax: 618-622-3468
Mailing address:
  • Phone: 217-324-1100
  • Fax: 217-324-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE MUDD
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 217-324-1100