Provider Demographics
NPI:1104830520
Name:ILLINI FAMILY MEDICINE
Entity Type:Organization
Organization Name:ILLINI FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:T
Authorized Official - Last Name:KINSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-444-3627
Mailing Address - Street 1:201 N CUMMINGS LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-2181
Mailing Address - Country:US
Mailing Address - Phone:309-444-3627
Mailing Address - Fax:309-444-7158
Practice Address - Street 1:201 N CUMMINGS LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2181
Practice Address - Country:US
Practice Address - Phone:309-444-3627
Practice Address - Fax:309-444-7158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE88299Medicare UPIN
IL956050Medicare PIN
ILP58881Medicare UPIN
ILR81397Medicare UPIN
ILE90653Medicare UPIN