Healthcare Provider Details

I. General information

NPI: 1841216975
Provider Name (Legal Business Name): PHYSICIANS GROUP ASSOCIATES S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 OLD JACKSONVILLE RD
SPRINGFIELD IL
62704-7437
US

IV. Provider business mailing address

PO BOX 500
CHATHAM IL
62629-0500
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-9722
  • Fax: 217-391-0392
Mailing address:
  • Phone: 217-670-2424
  • Fax: 217-670-2809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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