Provider Demographics
NPI:1689936874
Name:W H HOUSEWORTH, MD PC
Entity Type:Organization
Organization Name:W H HOUSEWORTH, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-345-3830
Mailing Address - Street 1:102 W BUCHANAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2522
Mailing Address - Country:US
Mailing Address - Phone:217-345-3830
Mailing Address - Fax:217-345-1018
Practice Address - Street 1:102 W BUCHANAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2522
Practice Address - Country:US
Practice Address - Phone:217-345-3830
Practice Address - Fax:217-345-1018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062033Medicaid
IL036062033Medicaid