Provider Demographics
NPI:1659312072
Name:FAMILY PRACTICE MEDICAL CENTER LTD
Entity Type:Organization
Organization Name:FAMILY PRACTICE MEDICAL CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GINDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-431-2025
Mailing Address - Street 1:511 W FAIRCHILD ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-3801
Mailing Address - Country:US
Mailing Address - Phone:217-431-2025
Mailing Address - Fax:217-431-0014
Practice Address - Street 1:511 W FAIRCHILD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3801
Practice Address - Country:US
Practice Address - Phone:217-431-2025
Practice Address - Fax:217-431-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2013-04-25
Deactivation Date:2008-06-10
Deactivation Code:
Reactivation Date:2009-10-23
Provider Licenses
StateLicense IDTaxonomies
IL036087566261QR1300X
IL036100736261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL015566OtherHEALTH ALLIANCE
IL036100736Medicaid
IL036087566Medicaid
IL09232019OtherBLUE CROSS BLUE SHIELD
IL015566OtherHEALTH ALLIANCE
IL09232019OtherBLUE CROSS BLUE SHIELD
IL036087566Medicaid
IL148935Medicare Oscar/Certification
ILH18897Medicare UPIN
IL09232019OtherBLUE CROSS BLUE SHIELD
IL=========002Medicaid