Healthcare Provider Details

I. General information

NPI: 1730217662
Provider Name (Legal Business Name): VINE ST CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 HEDLEY RD
SPRINGFIELD IL
62711-6248
US

IV. Provider business mailing address

3225 HEDLEY RD PO BOX 13484
SPRINGFIELD IL
62711-6248
US

V. Phone/Fax

Practice location:
  • Phone: 217-726-7300
  • Fax: 217-726-5989
Mailing address:
  • Phone: 217-726-7300
  • Fax: 217-726-5989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD B ALEXANDER
Title or Position: PARTNER
Credential: M.D.
Phone: 217-726-7300