Healthcare Provider Details

I. General information

NPI: 1275943508
Provider Name (Legal Business Name): PARTNERMD ILLINOIS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 DEAN ST UNIT C
ST CHARLES IL
60175-4827
US

IV. Provider business mailing address

7001 FOREST AVE SUITE 302
RICHMOND VA
23230-1726
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-2655
  • Fax:
Mailing address:
  • Phone: 804-282-2655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JAMES MUMPER
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 804-282-2655