Provider Demographics
NPI:1841216975
Name:PHYSICIANS GROUP ASSOCIATES S C
Entity Type:Organization
Organization Name:PHYSICIANS GROUP ASSOCIATES S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-698-9722
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-0500
Mailing Address - Country:US
Mailing Address - Phone:217-670-2424
Mailing Address - Fax:217-670-2809
Practice Address - Street 1:2901 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7437
Practice Address - Country:US
Practice Address - Phone:217-698-9722
Practice Address - Fax:217-391-0392
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIANS GROUP ASSOCIATES SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-14
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCD7143OtherRR MEDICARE GRP
IL020057300OtherBLACK LUNG
IL133586700OtherACS-OWCP
IL08421024OtherBLUE CROSS BLUE SHIELD
IL14D0949277OtherCLIA CERT#
IL6394POtherCATERPILLAR