Provider Demographics
NPI:1306822093
Name:SPRINGFIELD OBSTETRIC & GYNECOLOGIC ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:SPRINGFIELD OBSTETRIC & GYNECOLOGIC ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-525-0210
Mailing Address - Street 1:350 W CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4902
Mailing Address - Country:US
Mailing Address - Phone:217-525-0210
Mailing Address - Fax:217-525-1007
Practice Address - Street 1:350 W CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4902
Practice Address - Country:US
Practice Address - Phone:217-525-0210
Practice Address - Fax:217-525-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL694790Medicare ID - Type UnspecifiedMEDICARE