Provider Demographics
NPI:1033380514
Name:PRESTON SCOTT MEDICAL GROUP
Entity Type:Organization
Organization Name:PRESTON SCOTT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-547-9737
Mailing Address - Street 1:1906 PIERCE CT
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-1742
Mailing Address - Country:US
Mailing Address - Phone:815-547-9737
Mailing Address - Fax:815-547-9740
Practice Address - Street 1:1906 PIERCE CT
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1742
Practice Address - Country:US
Practice Address - Phone:815-547-9737
Practice Address - Fax:815-547-9740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110520207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216695Medicare PIN