Provider Demographics
NPI:1093711905
Name:FAMILY PHYSICIANS OF MADISON COUNTY LTD
Entity Type:Organization
Organization Name:FAMILY PHYSICIANS OF MADISON COUNTY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:K
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-5088
Mailing Address - Street 1:3 JUNCTION DR W
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2916
Mailing Address - Country:US
Mailing Address - Phone:618-288-5088
Mailing Address - Fax:
Practice Address - Street 1:3 JUNCTION DR W
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2916
Practice Address - Country:US
Practice Address - Phone:618-288-5088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6015373OtherBLUE SHIELD
IL080021119OtherRAIL ROAD MEDICARE
IL=========OtherTAX IDENTIFICATION NUMBER
IL6015373OtherBLUE SHIELD