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General NPI Number Information
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NPI Number | 1215141916
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Entity Type | Organization
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Legal Business Name | MT VERNON FAMILY PRACTICE PC
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Dates
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Enumeration Date | 05/10/2007
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Last Update Date | 08/12/2015
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Provider Practice Location Address
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Address Line | 4230 LINCOLNSHIRE DR STE G
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City | MOUNT VERNON
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State | IL
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Zip | 62864-2189
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Country | US
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Telephone | 618-244-6770
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Fax | 618-244-6772
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Provider Business Mailing Address
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Address Line | 4230 LINCOLNSHIRE DR STE G
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City | MOUNT VERNON
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State | IL
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Zip | 62864-2189
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Country | US
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Telephone | 618-244-6770
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Fax | 618-244-6772
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Authorized Official
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Title or Position | PRESIDENT
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Name | LINDEN R PEARSON
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Credential | M.D.
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Telephone | 618-244-6770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036063418
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License Number State | IL
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