Provider Demographics
NPI:1265688238
Name:ADULT INTERNAL MEDICINE PRACTICE LLC
Entity Type:Organization
Organization Name:ADULT INTERNAL MEDICINE PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:AMPADU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-257-0780
Mailing Address - Street 1:15 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2918
Mailing Address - Country:US
Mailing Address - Phone:618-257-0780
Mailing Address - Fax:618-355-9972
Practice Address - Street 1:15 PARK PL
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2918
Practice Address - Country:US
Practice Address - Phone:618-257-0780
Practice Address - Fax:618-257-0715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083270Medicaid
IL08227444OtherBCBS
32871OtherGHP
IL036083270Medicaid
339100Medicare PIN