Provider Demographics
NPI:1245252204
Name:MAPLE STREET CLINIC LTD
Entity type:Organization
Organization Name:MAPLE STREET CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HUNGERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-839-1561
Mailing Address - Street 1:1401 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-2223
Mailing Address - Country:US
Mailing Address - Phone:618-839-4618
Mailing Address - Fax:618-943-1700
Practice Address - Street 1:1401 15TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-2223
Practice Address - Country:US
Practice Address - Phone:618-839-4618
Practice Address - Fax:618-943-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360729422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072942Medicaid
ILC48402Medicare UPIN