Healthcare Provider Details

I. General information

NPI: 1508844325
Provider Name (Legal Business Name): KASKASKIA MEDICAL CENTER, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 N 8TH ST
VANDALIA IL
62471-1238
US

IV. Provider business mailing address

1003 N 8TH ST
VANDALIA IL
62471-1238
US

V. Phone/Fax

Practice location:
  • Phone: 618-283-4445
  • Fax: 618-283-4446
Mailing address:
  • Phone: 618-283-4445
  • Fax: 618-283-4446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036097600
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036097600
License Number StateIL

VIII. Authorized Official

Name: MICHAEL DARMADI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 618-283-4445