Provider Demographics
NPI:1598759516
Name:CROSSROADS PHYSICIAN CORP
Entity Type:Organization
Organization Name:CROSSROADS PHYSICIAN CORP
Other - Org Name:CROSSROADS FAMILY MEDICINE OF SALEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:1325 W WHITTAKER ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-2007
Mailing Address - Country:US
Mailing Address - Phone:618-548-4911
Mailing Address - Fax:618-548-8052
Practice Address - Street 1:1325 W WHITTAKER ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-2007
Practice Address - Country:US
Practice Address - Phone:618-548-4911
Practice Address - Fax:618-548-8052
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSROADS PHYSICIAN CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-06
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208459Medicare PIN