Provider Demographics
NPI:1649460510
Name:MACOUPIN FAMILY PRACTICE CENTERS, LLP
Entity type:Organization
Organization Name:MACOUPIN FAMILY PRACTICE CENTERS, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:QUARTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-854-4319
Mailing Address - Street 1:15574 ROUTE 108
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-4091
Mailing Address - Country:US
Mailing Address - Phone:217-854-4319
Mailing Address - Fax:217-854-2765
Practice Address - Street 1:15574 ROUTE 108
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-4091
Practice Address - Country:US
Practice Address - Phone:217-854-4319
Practice Address - Fax:217-854-2765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1649460510Medicaid