MEDICARE: CROSSROADS PHYSICIAN CORP

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		IL
2	207Q00000X	Family Medicine Physician		IL

General Provider Information

NPI Number	:	1598759516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROADS PHYSICIAN CORP

Provider Business Mailing Address
First Line	:	1325 W WHITTAKER ST
Second Line	:	SUITE 3
City	:	SALEM
State	:	IL
Zip	:	62881-2007
Country	:	US
Telephone Number	:	618-548-4911
Fax Number	:	618-548-8052

Provider Business Practice Location Address
First Line	:	1325 W WHITTAKER ST
Second Line	:	SUITE 3
City	:	SALEM
State	:	IL
Zip	:	62881-2007
Country	:	US
Telephone Number	:	618-548-4911
Fax Number	:	618-548-8052

Authorized Official
Title or Position	:	DIRECTOR OF PROVIDER ENROLLMENT
Name	:	DEBBIE T BREWER
Credential	:
Telephone Number	:	615-465-7626

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	09/18/2007

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Directions to “CROSSROADS PHYSICIAN CORP ” Practice Location

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