Provider Demographics
NPI:1720057730
Name:HEARTLAND OCCUPATIONAL MEDICINE PHYSICIANS OF ILLINOIS S C
Entity Type:Organization
Organization Name:HEARTLAND OCCUPATIONAL MEDICINE PHYSICIANS OF ILLINOIS S C
Other - Org Name:ULTIMED PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-242-4848
Mailing Address - Street 1:4117 S WATER TOWER PL
Mailing Address - Street 2:SUITE D
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6293
Mailing Address - Country:US
Mailing Address - Phone:618-242-4848
Mailing Address - Fax:618-242-4198
Practice Address - Street 1:4117 S WATER TOWER PL
Practice Address - Street 2:SUITE D
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6293
Practice Address - Country:US
Practice Address - Phone:618-242-4848
Practice Address - Fax:618-242-4198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
209237Medicare ID - Type Unspecified