Provider Demographics
NPI:1750353454
Name:MEDICAL ASSOCIATES OF JERSEYVILLE, LTD.
Entity type:Organization
Organization Name:MEDICAL ASSOCIATES OF JERSEYVILLE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BENWARE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:618-498-7108
Mailing Address - Street 1:PO BOX 364
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-0364
Mailing Address - Country:US
Mailing Address - Phone:618-498-7108
Mailing Address - Fax:618-498-7919
Practice Address - Street 1:270 MAPLE SUMMIT RD
Practice Address - Street 2:MCDOW BUILDING
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2004
Practice Address - Country:US
Practice Address - Phone:618-498-7108
Practice Address - Fax:618-498-7919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042007207OtherCORPORATE LICENSE
IL=========001Medicaid
IL042007207OtherCORPORATE LICENSE
IL143892Medicare Oscar/Certification