Provider Demographics
NPI:1508844325
Name:KASKASKIA MEDICAL CENTER, LTD
Entity Type:Organization
Organization Name:KASKASKIA MEDICAL CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DARMADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-283-4445
Mailing Address - Street 1:1003 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1238
Mailing Address - Country:US
Mailing Address - Phone:618-283-4445
Mailing Address - Fax:618-283-4446
Practice Address - Street 1:1003 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1238
Practice Address - Country:US
Practice Address - Phone:618-283-4445
Practice Address - Fax:618-283-4446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097600207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097600Medicaid
IL562840Medicare PIN
G24797Medicare UPIN