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General NPI Number Information
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NPI Number | 1801920889
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICINE OF MCLEANSBORO LLC
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 208 S WASHINGTON ST
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City | MCLEANSBORO
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State | IL
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Zip | 62859-1139
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Country | US
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Telephone | 618-643-2835
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Fax | 618-643-2891
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Provider Business Mailing Address
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Address Line | 208 SOUTH WASHINGTON STREET
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City | MCLEANSBORO
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State | IL
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Zip | 62859
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Country | US
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Telephone | 618-643-2835
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Fax | 618-643-2891
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Authorized Official
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Title or Position | MANAGER
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Name | MICHAEL S DAVENPORT
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Credential | FNP
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Telephone | 618-927-8714
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State | IL
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