Provider Demographics
NPI:1821283466
Name:PROGRESSIVE WELLNESS CENTER
Entity Type:Organization
Organization Name:PROGRESSIVE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-585-7910
Mailing Address - Street 1:5220 S 6TH STREET RD
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5735
Mailing Address - Country:US
Mailing Address - Phone:217-529-0300
Mailing Address - Fax:217-529-2606
Practice Address - Street 1:5220 S 6TH STREET RD
Practice Address - Street 2:SUITE 1500
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5735
Practice Address - Country:US
Practice Address - Phone:217-529-0300
Practice Address - Fax:217-529-2606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8432119OtherBLUE SHIELD OF ILLINOIS