Provider Demographics
NPI:1003040387
Name:ILLINOIS ASSOCIATES PSYCHIATRY P C
Entity Type:Organization
Organization Name:ILLINOIS ASSOCIATES PSYCHIATRY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC CCS-P
Authorized Official - Phone:618-656-2000
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0790
Mailing Address - Country:US
Mailing Address - Phone:618-656-2000
Mailing Address - Fax:
Practice Address - Street 1:817 N STANFORD RD
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-3243
Practice Address - Country:US
Practice Address - Phone:618-656-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINOIS ASSOCIATES PSYCHIATRY P C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-14
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060006403104100000X, 1041C0700X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty