Provider Demographics
NPI:1750639480
Name:CLARK COUNTY FAMILY MEDICINE
Entity Type:Organization
Organization Name:CLARK COUNTY FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:GALEENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-382-4191
Mailing Address - Street 1:890 RIDGELAWN RD
Mailing Address - Street 2:PO BOX 399
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62442-0399
Mailing Address - Country:US
Mailing Address - Phone:217-382-4191
Mailing Address - Fax:217-382-4248
Practice Address - Street 1:890 RIDGELAWN RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62442-0399
Practice Address - Country:US
Practice Address - Phone:217-382-4191
Practice Address - Fax:217-382-4248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DR9170OtherRAILROAD MEDICARE
IL=========001Medicaid
DR9170OtherRAILROAD MEDICARE