Provider Demographics
NPI:1588675482
Name:HEALTHCARE NETWORK ASSOCIATES OF SANGAMON
Entity Type:Organization
Organization Name:HEALTHCARE NETWORK ASSOCIATES OF SANGAMON
Other - Org Name:MEMORIAL EXPRESS CARE AT KOKE MILL
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 1:3132 OLD JACKSONVILLE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7400
Practice Address - Country:US
Practice Address - Phone:217-862-0062
Practice Address - Fax:217-862-0064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL313780Medicare ID - Type Unspecified
IL1304260003Medicare NSC