Provider Demographics
NPI:1477743342
Name:MACOUPIN FAMILY PRACTICE CENTERS, LLP
Entity Type:Organization
Organization Name:MACOUPIN FAMILY PRACTICE CENTERS, LLP
Other - Org Name:MT OLIVE FAMILY PRACTICE CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:F
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-839-4491
Mailing Address - Street 1:115 N POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:IL
Mailing Address - Zip Code:62069-1613
Mailing Address - Country:US
Mailing Address - Phone:217-999-4751
Mailing Address - Fax:217-999-2317
Practice Address - Street 1:115 N POPLAR ST
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:IL
Practice Address - Zip Code:62069-1613
Practice Address - Country:US
Practice Address - Phone:217-999-4751
Practice Address - Fax:217-999-2317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid