Provider Demographics
NPI:1114114345
Name:MURPHYSBORO INTERNAL MEDICINE CLINIC
Entity Type:Organization
Organization Name:MURPHYSBORO INTERNAL MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANTE
Authorized Official - Middle Name:T
Authorized Official - Last Name:TRINH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-684-6408
Mailing Address - Street 1:1032 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-2267
Mailing Address - Country:US
Mailing Address - Phone:618-684-6408
Mailing Address - Fax:618-684-3637
Practice Address - Street 1:1032 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2267
Practice Address - Country:US
Practice Address - Phone:618-684-6408
Practice Address - Fax:618-684-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110916207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03932025OtherBC BS IL
IL036110916Medicaid
IL036110916Medicaid
IL209134Medicare PIN