Provider Demographics
NPI:1437268604
Name:SPOON RIVER FAMILY PRACTICE CENTER, INC
Entity Type:Organization
Organization Name:SPOON RIVER FAMILY PRACTICE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FORESTIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-647-9980
Mailing Address - Street 1:45 E SIDE SQ
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2671
Mailing Address - Country:US
Mailing Address - Phone:309-647-9980
Mailing Address - Fax:
Practice Address - Street 1:45 E SIDE SQ
Practice Address - Street 2:SUITE 102
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2671
Practice Address - Country:US
Practice Address - Phone:309-647-9980
Practice Address - Fax:309-647-7792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL0101OtherJOHN DEERE PROVIDER #
DA4719OtherMEDICARE RAILROAD GROUP #
IL0002932001OtherBLUE CROSS PROVIDER #
IL014152OtherHEALTH ALLIANCE PROVDIER
DA4719OtherMEDICARE RAILROAD GROUP #