Provider Demographics
NPI:1396034245
Name:MIDWEST EMERGENCY CENTRALIA CAMPUS ASSOCIATES, INC
Entity Type:Organization
Organization Name:MIDWEST EMERGENCY CENTRALIA CAMPUS ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:CRUZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-451-4208
Mailing Address - Street 1:6451 BRENTWOOD STAIR ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-3200
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:817-563-3699
Practice Address - Street 1:400 NORTH PLEASANT AVENUE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3056
Practice Address - Country:US
Practice Address - Phone:817-451-4208
Practice Address - Fax:817-563-3699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty