Provider Demographics
NPI:1619485828
Name:PRIORITY MEDICAL GROUP SC
Entity Type:Organization
Organization Name:PRIORITY MEDICAL GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SONDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-967-2964
Mailing Address - Street 1:905 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-4112
Mailing Address - Country:US
Mailing Address - Phone:618-988-6000
Mailing Address - Fax:
Practice Address - Street 1:905 S PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-4112
Practice Address - Country:US
Practice Address - Phone:618-942-7376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty