=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538775192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DISCOVER INTEGRATED MEDICAL CENTER, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2020
-----------------------------------------------------
Last Update Date | 09/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2207 N US HIGHWAY 12 STE E
-----------------------------------------------------
City | SPRING GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60081-9706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-675-9355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2207 N US HIGHWAY 12 STE E
-----------------------------------------------------
City | SPRING GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60081-9706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-675-9355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | DARRIN FOSZCZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-675-9355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------