MEDICARE: NORTH DIRKSEN MEDICAL ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1063646040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH DIRKSEN MEDICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 3428
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62708-3428
Country	:	US
Telephone Number	:	800-577-5368
Fax Number	:	217-757-2021

Provider Business Practice Location Address
First Line	:	3220 ATLANTA ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62707-8801
Country	:	US
Telephone Number	:	217-588-7400
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT HCNA AND OPERATIONS
Name	:	J. TRAVIS DOWELL
Credential	:
Telephone Number	:	217-788-3342

Provider Enumeration Date	:	05/06/2009
Last Update Date	:	05/06/2009

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