Provider Demographics
NPI:1255587176
Name:MIDWEST NEUROLOGY ASSOCIATES, S.C.
Entity type:Organization
Organization Name:MIDWEST NEUROLOGY ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:LYNICE
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-872-7000
Mailing Address - Street 1:302 W HAY ST
Mailing Address - Street 2:SUITE LL110
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4167
Mailing Address - Country:US
Mailing Address - Phone:217-872-7000
Mailing Address - Fax:217-233-1564
Practice Address - Street 1:302 W HAY ST
Practice Address - Street 2:SUITE LL110
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4167
Practice Address - Country:US
Practice Address - Phone:217-872-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093353174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093353Medicaid