Provider Demographics
NPI:1669654224
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:I
Authorized Official - Credentials:MD
Authorized Official - Phone:217-516-0715
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 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:IL
Practice Address - Zip Code:61846-1728
Practice Address - Country:US
Practice Address - Phone:217-662-2282
Practice Address - Fax:217-662-6946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL148956Medicare Oscar/Certification
IL=========001Medicaid
IL702130Medicare Oscar/Certification