Provider Demographics
NPI:1649283870
Name:PHYSICIAN RURAL HEALTH CLINIC OF JEFFERSON COUNTY
Entity type:Organization
Organization Name:PHYSICIAN RURAL HEALTH CLINIC OF JEFFERSON COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VEENA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-244-7200
Mailing Address - Street 1:3307 BROADWAY ST
Mailing Address - Street 2:STE 130
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2347
Mailing Address - Country:US
Mailing Address - Phone:618-244-2560
Mailing Address - Fax:618-244-1572
Practice Address - Street 1:3307 BROADWAY ST
Practice Address - Street 2:STE 130
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2347
Practice Address - Country:US
Practice Address - Phone:618-244-2560
Practice Address - Fax:618-244-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL143949Medicare Oscar/Certification