Provider Demographics
NPI:1710159686
Name:PROGRESSIVE FAMILY CARE LTD.
Entity Type:Organization
Organization Name:PROGRESSIVE FAMILY CARE LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:NELS
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-281-2273
Mailing Address - Street 1:208 N MAIN ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1756
Mailing Address - Country:US
Mailing Address - Phone:618-281-2273
Mailing Address - Fax:618-281-0245
Practice Address - Street 1:208 N MAIN ST
Practice Address - Street 2:SUITE H
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1756
Practice Address - Country:US
Practice Address - Phone:618-281-2273
Practice Address - Fax:618-281-0245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROGRESSIVE FAMILY CARE LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG3299OtherMEDICARE RR
=========OtherTAX ID
=========OtherTAX ID
DG3299OtherMEDICARE RR