MEDICARE: JOHNSTON CITY MEDICAL CLINIC, S. C.

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	261QR1300X	Rural Health Clinic/Center		IL

General Provider Information

NPI Number	:	1962428516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSTON CITY MEDICAL CLINIC, S. C.

Provider Business Mailing Address
First Line	:	201 W BROADWAY BLVD
Second Line	:	P. O. BOX 209
City	:	JOHNSTON CITY
State	:	IL
Zip	:	62951-1427
Country	:	US
Telephone Number	:	618-983-6911
Fax Number	:	618-983-6913

Provider Business Practice Location Address
First Line	:	201 W BROADWAY BLVD
Second Line	:
City	:	JOHNSTON CITY
State	:	IL
Zip	:	62951-1427
Country	:	US
Telephone Number	:	618-983-6911
Fax Number	:	618-983-6913

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. KHALID JAVED
Credential	:	M.D.
Telephone Number	:	618-983-6911

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	08/22/2020

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