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General NPI Number Information
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NPI Number | 1619485828
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Entity Type | Organization
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Legal Business Name | PRIORITY MEDICAL GROUP SC
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Dates
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Enumeration Date | 01/22/2018
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Last Update Date | 12/03/2021
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Provider Practice Location Address
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Address Line | 905 S PARK AVE
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City | HERRIN
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State | IL
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Zip | 62948-4112
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Country | US
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Telephone | 618-942-7376
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Fax |
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Provider Business Mailing Address
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Address Line | 905 S PARK AVE
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City | HERRIN
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State | IL
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Zip | 62948-4112
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Country | US
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Telephone | 618-988-6000
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Fax |
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Authorized Official
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Title or Position | BUSINESS ADMINISTRATOR
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Name | SONDRA HUMPHREYS
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Credential |
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Telephone | 618-967-2964
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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 |
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License Number State |
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