Provider Demographics
NPI:1366639759
Name:RURAL FAMILY MEDICINE ASSOCIATES, LTD
Entity Type:Organization
Organization Name:RURAL FAMILY MEDICINE ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:RABEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-566-8810
Mailing Address - Street 1:739 N JEFFERSON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-1447
Mailing Address - Country:US
Mailing Address - Phone:618-566-8810
Mailing Address - Fax:618-566-7121
Practice Address - Street 1:739 N JEFFERSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-1447
Practice Address - Country:US
Practice Address - Phone:618-566-8810
Practice Address - Fax:618-566-7121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042007909207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
382430Medicare PIN