Provider Demographics
NPI:1598000770
Name:BAYVIEW FAMILY CLINIC LTD
Entity Type:Organization
Organization Name:BAYVIEW FAMILY CLINIC LTD
Other - Org Name:DANVILLE PEDIATRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BAMIDELE
Authorized Official - Middle Name:
Authorized Official - Last Name:EKUNSANMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-336-3288
Mailing Address - Street 1:206 BURWASH AVE
Mailing Address - Street 2:
Mailing Address - City:SAVOY
Mailing Address - State:IL
Mailing Address - Zip Code:61874-9510
Mailing Address - Country:US
Mailing Address - Phone:217-356-3400
Mailing Address - Fax:217-866-0122
Practice Address - Street 1:405 N. SHERIDAN ST.
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-446-3259
Practice Address - Fax:217-446-4132
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYVIEW FAMILY CLINIC LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-29
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112430302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization