Provider Demographics
NPI:1578226569
Name:NATIONWIDE MEDICAL NETWORK
Entity Type:Organization
Organization Name:NATIONWIDE MEDICAL NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RACHEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-477-9640
Mailing Address - Street 1:4020 GREEN MOUNT CROSSING DR STE 143
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1333 CENTRAL PARK DRIVE SUITE 102
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-477-4960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10892503OtherARTICLES OF ORGANIZATION
IL10892503OtherARTICLES OF ORANIZATION