Provider Demographics
NPI:1174661870
Name:HARRISBURG FAMILY PRACTICE LTD
Entity Type:Organization
Organization Name:HARRISBURG FAMILY PRACTICE LTD
Other - Org Name:SLOAN MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOATRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-252-8625
Mailing Address - Street 1:117 E CLARK ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2702
Mailing Address - Country:US
Mailing Address - Phone:618-252-8625
Mailing Address - Fax:618-252-2540
Practice Address - Street 1:7211 US HIGHWAY 45 S
Practice Address - Street 2:SUITE C
Practice Address - City:CARRIER MILLS
Practice Address - State:IL
Practice Address - Zip Code:62917
Practice Address - Country:US
Practice Address - Phone:618-994-2321
Practice Address - Fax:618-994-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL143958Medicare Oscar/Certification