Healthcare Provider Details

I. General information

NPI: 1598759516
Provider Name (Legal Business Name): CROSSROADS PHYSICIAN CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 09/18/2007
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: 618-548-4911
  • Fax: 618-548-8052
Mailing address:
  • Phone: 618-548-4911
  • Fax: 618-548-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7626