Provider Demographics
NPI:1407835200
Name:ACCESS HEALTHCARE CLINIC LTD
Entity Type:Organization
Organization Name:ACCESS HEALTHCARE CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTICE
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:GONDWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-792-8545
Mailing Address - Street 1:1180 AVENUE OF THE CITIES
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4110
Mailing Address - Country:US
Mailing Address - Phone:309-792-8545
Mailing Address - Fax:309-792-8566
Practice Address - Street 1:1180 AVENUE OF THE CITIES
Practice Address - Street 2:SUITE 1
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4110
Practice Address - Country:US
Practice Address - Phone:309-792-8545
Practice Address - Fax:309-792-8566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI11536Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ILF87739Medicare UPIN
IL208581Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER