Provider Demographics
NPI:1942312442
Name:ALTON MULTISPECIALISTS, LTD.
Entity Type:Organization
Organization Name:ALTON MULTISPECIALISTS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-463-8634
Mailing Address - Street 1:1 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5068
Mailing Address - Country:US
Mailing Address - Phone:618-463-8500
Mailing Address - Fax:618-474-0130
Practice Address - Street 1:1 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5068
Practice Address - Country:US
Practice Address - Phone:618-463-8500
Practice Address - Fax:618-474-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071248207R00000X
IL100867261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MammographyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207219OtherPTAN
0317160001OtherMEDICARE DME SUPPLIER
IL687340OtherPTAN
IL06015403OtherBLUE CROSS/BLUE SHIELD
IL207219OtherPTAN
IL687340Medicare PIN