Provider Demographics
NPI:1669464178
Name:TREMONT MEDICAL CLINIC SC
Entity Type:Organization
Organization Name:TREMONT MEDICAL CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOBART
Authorized Official - Middle Name:DON
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:309-925-2961
Mailing Address - Street 1:105 S LOCUST ST
Mailing Address - Street 2:PO BOX 187
Mailing Address - City:TREMONT
Mailing Address - State:IL
Mailing Address - Zip Code:61568-0187
Mailing Address - Country:US
Mailing Address - Phone:309-925-2961
Mailing Address - Fax:309-925-4221
Practice Address - Street 1:105 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:TREMONT
Practice Address - State:IL
Practice Address - Zip Code:61568-0187
Practice Address - Country:US
Practice Address - Phone:309-925-2961
Practice Address - Fax:309-925-4221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9015656OtherBCBS
C10889OtherRAILROAD MEDICARE
9015656OtherBCBS