Provider Demographics
NPI:1841578507
Name:PASSAVANT PHYSICIAN ASSOCIATION
Entity Type:Organization
Organization Name:PASSAVANT PHYSICIAN ASSOCIATION
Other - Org Name:WOUND CLINIC RHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PLAN ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-479-5890
Mailing Address - Street 1:1600 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1136
Mailing Address - Country:US
Mailing Address - Phone:217-245-9541
Mailing Address - Fax:
Practice Address - Street 1:1600 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1136
Practice Address - Country:US
Practice Address - Phone:217-245-9541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098965207Q00000X
IL209007563363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty