Provider Demographics
NPI:1568619088
Name:MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC
Other - Org Name:DIETERICH COMMUNITY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF MID-ILLINOIS MEDICAL C
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DUST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-347-2707
Mailing Address - Street 1:1207 NETWORK CENTRE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4632
Mailing Address - Country:US
Mailing Address - Phone:217-347-2707
Mailing Address - Fax:217-347-2827
Practice Address - Street 1:203 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:DIETERICH
Practice Address - State:IL
Practice Address - Zip Code:62424
Practice Address - Country:US
Practice Address - Phone:217-925-5730
Practice Address - Fax:217-925-5736
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120332261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120332Medicaid
IL036120332Medicaid
IL561920Medicare PIN