Provider Demographics
NPI:1538293741
Name:FAMILY PHYSICIANS CENTER OF MASSAC COUNTY SC
Entity Type:Organization
Organization Name:FAMILY PHYSICIANS CENTER OF MASSAC COUNTY SC
Other - Org Name:FAMILY PHYSICIANS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:E
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-524-3795
Mailing Address - Street 1:1203 WEST 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2433
Mailing Address - Country:US
Mailing Address - Phone:618-524-3795
Mailing Address - Fax:618-524-3211
Practice Address - Street 1:1203 WEST 10TH STREET
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2433
Practice Address - Country:US
Practice Address - Phone:618-524-3795
Practice Address - Fax:618-524-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7281Medicare PIN
IL376210Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER