Provider Demographics
NPI:1366637258
Name:JEFFERSON STREET CLINIC, SC
Entity Type:Organization
Organization Name:JEFFERSON STREET CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:309-266-9711
Mailing Address - Street 1:107 E JEFFERSON ST
Mailing Address - Street 2:PO BOX 180
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2001
Mailing Address - Country:US
Mailing Address - Phone:309-266-9711
Mailing Address - Fax:309-266-6322
Practice Address - Street 1:107 E JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-0180
Practice Address - Country:US
Practice Address - Phone:309-266-9711
Practice Address - Fax:309-266-6322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9015653OtherBLUE CROSS BLUE SHIELD
IL962670Medicare UPIN