Provider Demographics
NPI:1457503591
Name:ILLINOIS-INDIANA EM-I MEDICAL SERVICES S C
Entity Type:Organization
Organization Name:ILLINOIS-INDIANA EM-I MEDICAL SERVICES S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-450-4684
Mailing Address - Street 1:PO BOX 80175
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-1175
Mailing Address - Country:US
Mailing Address - Phone:003-553-8188
Mailing Address - Fax:610-834-9292
Practice Address - Street 1:1400 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2334
Practice Address - Country:US
Practice Address - Phone:217-337-2000
Practice Address - Fax:217-337-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X
IL363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty