Provider Demographics
NPI:1477019909
Name:FAMILY MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-324-1100
Mailing Address - Street 1:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-0483
Mailing Address - Country:US
Mailing Address - Phone:217-324-1100
Mailing Address - Fax:217-324-1103
Practice Address - Street 1:1480 N GREEN MOUNT RD SUITE 200
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3466
Practice Address - Country:US
Practice Address - Phone:618-622-3450
Practice Address - Fax:618-622-3468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDZ1647OtherRAILROAD MEDICARE PTAN