Provider Demographics
NPI:1376014175
Name:EDWARDSVILLE PHYSICIANS GROUP LLC
Entity type:Organization
Organization Name:EDWARDSVILLE PHYSICIANS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARBISON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-254-2273
Mailing Address - Street 1:441 SOUTH STATE ROUTE 157 SUITE 102
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-4012
Mailing Address - Country:US
Mailing Address - Phone:618-254-2273
Mailing Address - Fax:618-254-8476
Practice Address - Street 1:441 SOUTH STATE ROUTE 157 SUITE 102
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-4012
Practice Address - Country:US
Practice Address - Phone:618-254-2273
Practice Address - Fax:618-254-8476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty