Provider Demographics
NPI:1033841192
Name:HSHS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:HSHS MEDICAL GROUP INC
Other - Org Name:HSHS MEDICAL GROUP FAMILY MEDICINE - DIETERICH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HODGKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-485-4178
Mailing Address - Street 1:3051 HOLLIS DR FL 2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DIETERICH
Practice Address - State:IL
Practice Address - Zip Code:62424-1128
Practice Address - Country:US
Practice Address - Phone:217-925-5730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HSHS MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-28
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health