=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669459129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIA A BANCROFT DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2005
-----------------------------------------------------
Last Update Date | 10/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6294 STATE HWY 154
-----------------------------------------------------
City | SESSER
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-625-6979
-----------------------------------------------------
Fax | 618-625-5362
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 155 CHRISTOPHER GREATER AREA RURAL HEALTH PLANNING CORP
-----------------------------------------------------
City | CHRISTOPHER
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-724-2401
-----------------------------------------------------
Fax | 618-724-2571
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036098406
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------