Provider Demographics
NPI:1225289861
Name:KOKE MILL MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:KOKE MILL MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT HCNA AND OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:J. TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-788-3342
Mailing Address - Street 1:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:800-577-5368
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:3132 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7400
Practice Address - Country:US
Practice Address - Phone:217-862-0800
Practice Address - Fax:217-862-0871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty