Provider Demographics
NPI:1972722833
Name:PROGRESSIVE FAMILY CARE, LTD
Entity Type:Organization
Organization Name:PROGRESSIVE FAMILY CARE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:NELS
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-939-2273
Mailing Address - Street 1:509 HAMACHER ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1592
Mailing Address - Country:US
Mailing Address - Phone:618-939-2273
Mailing Address - Fax:618-939-0245
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-2273
Practice Address - Fax:618-939-0245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG3299OtherMEDICARE RR
DG3299OtherMEDICARE RR
6093540001Medicare NSC
215453Medicare PIN