Provider Demographics
NPI:1972597060
Name:CROSSROADS PHYSICIAN CORP
Entity Type:Organization
Organization Name:CROSSROADS PHYSICIAN CORP
Other - Org Name:CROSSROADS FAMILY MEDICINE OF WAYNE CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-628-6038
Mailing Address - Street 1:1209 W ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62895-9672
Mailing Address - Country:US
Mailing Address - Phone:618-895-2050
Mailing Address - Fax:618-895-2056
Practice Address - Street 1:1209 W ROBINSON ST
Practice Address - Street 2:
Practice Address - City:WAYNE CITY
Practice Address - State:IL
Practice Address - Zip Code:62895-9672
Practice Address - Country:US
Practice Address - Phone:618-895-2050
Practice Address - Fax:618-895-2056
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSROADS PHYSICIAN CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-06
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036041176Medicaid
IL036041176Medicaid
IL036041176Medicaid