Provider Demographics
NPI:1679637789
Name:CROSSROADS PHYSICIAN CORP
Entity Type:Organization
Organization Name:CROSSROADS PHYSICIAN CORP
Other - Org Name:CROSSROADS INTERNAL MEDICINE #3
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 1:1 DOCTORS PARK RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6251
Mailing Address - Country:US
Mailing Address - Phone:618-242-1397
Mailing Address - Fax:618-242-9002
Practice Address - Street 1:1 DOCTORS PARK RD
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6251
Practice Address - Country:US
Practice Address - Phone:618-242-1397
Practice Address - Fax:618-242-9002
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSROADS PHYSICIAN CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-21
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL599560Medicare PIN
IL208459Medicare PIN
IL212649Medicare PIN