Provider Demographics
NPI:1568471464
Name:HEALTHCARE NETWORK ASSOCIATES OF SANGAMON
Entity Type:Organization
Organization Name:HEALTHCARE NETWORK ASSOCIATES OF SANGAMON
Other - Org Name:JACKSONVILLE FAMILY MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:KENDRICK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:217-757-7493
Mailing Address - Street 1:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:217-757-7491
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:1602 W LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1007
Practice Address - Country:US
Practice Address - Phone:217-243-7200
Practice Address - Fax:217-243-6165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL313780Medicare ID - Type Unspecified