Provider Demographics
NPI:1972614808
Name:GALESBURG CLINIC PC
Entity Type:Organization
Organization Name:GALESBURG CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:H
Authorized Official - Last Name:MICHALEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-344-9371
Mailing Address - Street 1:3315 N SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1251
Mailing Address - Country:US
Mailing Address - Phone:309-344-9371
Mailing Address - Fax:309-344-1054
Practice Address - Street 1:3315 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1251
Practice Address - Country:US
Practice Address - Phone:309-344-9371
Practice Address - Fax:309-344-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4815127OtherB/C B/S
IL938220Medicare ID - Type Unspecified
IL902600Medicare ID - Type Unspecified
IL4815127OtherB/C B/S
IL0321590001Medicare NSC