Provider Demographics
NPI:1841237583
Name:DAVID P DAVIS MEDICINE, PC
Entity Type:Organization
Organization Name:DAVID P DAVIS MEDICINE, PC
Other - Org Name:CLARK COUNTY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:2006-06-01
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086811261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL316704395Medicaid
IL0004400750OtherAETNA
IL238297OtherHEALTHLINK
IL006686OtherHEALTH ALLIANCE
IN000000079566OtherANTHEM
IL01225376OtherBLUE CROSS BLUE SHIELD
IL006686OtherHEALTH ALLIANCE
IL========= 05OtherSAGAMORE
IL0004400750OtherAETNA
IL01225376OtherBLUE CROSS BLUE SHIELD
IL=========001Medicaid
IL238297OtherHEALTHLINK
IN142940Medicare ID - Type UnspecifiedINDIANA MEDICARE