Healthcare Provider Details

I. General information

NPI: 1356331078
Provider Name (Legal Business Name): WEST SALEM CLINIC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S MAIN ST
WEST SALEM IL
62476-1202
US

IV. Provider business mailing address

100 S MAIN ST PO BOX 306
WEST SALEM IL
62476-1202
US

V. Phone/Fax

Practice location:
  • Phone: 618-456-3727
  • Fax: 618-456-3774
Mailing address:
  • Phone: 618-456-3727
  • Fax: 618-456-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: HARRY TIMOTHY GARRETT
Title or Position: PHYSICIAN PRESIDENT
Credential:
Phone: 618-456-3727