Healthcare Provider Details

I. General information

NPI: 1700065851
Provider Name (Legal Business Name): SALEM FAMILY PRACTICE, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 W WHITTAKER ST SUITE #3
SALEM IL
62881-2007
US

IV. Provider business mailing address

1325 W WHITTAKER ST SUITE #3
SALEM IL
62881-2007
US

V. Phone/Fax

Practice location:
  • Phone: 618-740-0341
  • Fax: 618-740-0343
Mailing address:
  • Phone: 618-740-0341
  • Fax: 618-740-0343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: JEFFREY B KESSLER
Title or Position: PRESIDENT
Credential: MD
Phone: 618-548-1330