Provider Demographics
NPI:1922007533
Name:NEW CENTURY PHYSICIANS OF SOUTHERN ILLINOIS INC
Entity Type:Organization
Organization Name:NEW CENTURY PHYSICIANS OF SOUTHERN ILLINOIS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:800-726-3627
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:3333 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5884
Practice Address - Country:US
Practice Address - Phone:618-998-7000
Practice Address - Fax:618-997-6589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1443332207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10032029OtherBC/BS GRP PROVIDER #
IL610626900OtherFEDERAL BLACK LUNG
IL610626900OtherDEPT OF LABOR
IL610626900OtherEEOIC
IL610626900OtherDEPT OF LABOR
IL610626900OtherEEOIC