Provider Demographics
NPI:1689874182
Name:BUNKER HILL MEDICAL CLINIC
Entity Type:Organization
Organization Name:BUNKER HILL MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-585-6290
Mailing Address - Street 1:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:BUNKER HILL
Mailing Address - State:IL
Mailing Address - Zip Code:62014-0323
Mailing Address - Country:US
Mailing Address - Phone:618-585-6290
Mailing Address - Fax:618-585-6293
Practice Address - Street 1:144 NORTH WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:BUNKER HILL
Practice Address - State:IL
Practice Address - Zip Code:62014
Practice Address - Country:US
Practice Address - Phone:618-585-6290
Practice Address - Fax:618-585-6293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9900567OtherBLUE CROSS BLUE SHIELD
C43578OtherUPIN
134799OtherHEALTHLINK
IL036063415Medicaid
IL=========OtherTAX ID
C43578OtherUPIN
134799OtherHEALTHLINK
IL=========OtherTAX ID
C43578OtherUPIN
IL148982Medicare Oscar/Certification