Provider Demographics
NPI:1154306397
Name:FAMILY PRACTICE ASSOCIATES OF MACOMB LTD
Entity Type:Organization
Organization Name:FAMILY PRACTICE ASSOCIATES OF MACOMB LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-833-1733
Mailing Address - Street 1:505 E GRANT ST
Mailing Address - Street 2:SUITE 110 FAMILY PRACTICE ASSOCIATES OF MACOMB LTD
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3352
Mailing Address - Country:US
Mailing Address - Phone:309-833-1733
Mailing Address - Fax:309-836-2369
Practice Address - Street 1:505 E GRANT ST
Practice Address - Street 2:SUITE 110 FAMILY PRACTICE ASSOCIATES OF MACOMB LTD
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3352
Practice Address - Country:US
Practice Address - Phone:309-833-1733
Practice Address - Fax:309-836-2369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2020-08-22
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
962300Medicare ID - Type Unspecified