Provider Demographics
NPI:1598125031
Name:PRIORITY HEALTH FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:PRIORITY HEALTH FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-330-9788
Mailing Address - Street 1:5160 HICKORY POINT FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-9778
Mailing Address - Country:US
Mailing Address - Phone:217-330-9788
Mailing Address - Fax:217-330-8945
Practice Address - Street 1:5160 HICKORY POINT FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-9778
Practice Address - Country:US
Practice Address - Phone:217-330-9788
Practice Address - Fax:217-330-8945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107742207Q00000X
IL036092026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG28399Medicare UPIN
ILH77480Medicare UPIN