Provider Demographics
NPI:1093150567
Name:MEDICAL SERVICE CORPORATION SC
Entity Type:Organization
Organization Name:MEDICAL SERVICE CORPORATION SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MRS
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:815-252-1805
Mailing Address - Street 1:405 BRONCO DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-5393
Mailing Address - Country:US
Mailing Address - Phone:815-252-1805
Mailing Address - Fax:815-663-0103
Practice Address - Street 1:104 W 6TH ST STE 206
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2864
Practice Address - Country:US
Practice Address - Phone:815-252-1805
Practice Address - Fax:815-663-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty