Provider Demographics
NPI:1518285295
Name:CARLINVILLE MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:CARLINVILLE MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-854-9411
Mailing Address - Street 1:604 N BROAD
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1608
Mailing Address - Country:US
Mailing Address - Phone:217-854-9411
Mailing Address - Fax:217-854-2858
Practice Address - Street 1:604 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1021
Practice Address - Country:US
Practice Address - Phone:217-854-9411
Practice Address - Fax:217-854-2858
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARLINVILLE MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-05
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057724207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5930138OtherBLUE CROSS/BLUE SHIELD
IL5930138OtherBLUE CROSS/BLUE SHIELD
IL624840Medicare PIN
ILC45428Medicare UPIN
IL5930138OtherBLUE CROSS/BLUE SHIELD
IL148978Medicare Oscar/Certification
ILK23646Medicare PIN