Provider Demographics
NPI:1568651925
Name:MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC
Other - Org Name:DR. DUST
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT OF LLC
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:217-347-5917
Mailing Address - Street 1:1207 NETWORK CENTRE DR STE 3
Mailing Address - Street 2:
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 1:900 W TEMPLE AVE STE 205
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2187
Practice Address - Country:US
Practice Address - Phone:217-347-0458
Practice Address - Fax:217-342-2992
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-22
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL148959Medicare Oscar/Certification