=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528393410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HSHS MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2009
-----------------------------------------------------
Last Update Date | 05/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1520 9TH ST
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62249-1677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-654-6444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1520 9TH ST
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62249-1677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MR. CHRISTOPHER FRANKLIN
-----------------------------------------------------
Credential | MHA
-----------------------------------------------------
Telephone | 618-651-2860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------