Provider Demographics
NPI:1356331078
Name:WEST SALEM CLINIC LTD
Entity Type:Organization
Organization Name:WEST SALEM CLINIC LTD
Other - Org Name:FAMILY PRACTICE ASSOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-456-3727
Mailing Address - Street 1:100 S MAIN ST
Mailing Address - Street 2:PO BOX 306
Mailing Address - City:WEST SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62476-1202
Mailing Address - Country:US
Mailing Address - Phone:618-456-3727
Mailing Address - Fax:618-456-3774
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:IL
Practice Address - Zip Code:62476-1202
Practice Address - Country:US
Practice Address - Phone:618-456-3727
Practice Address - Fax:618-456-3774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C45977Medicare UPIN
IL143900Medicare Oscar/Certification
ILK30397Medicare PIN