Provider Demographics
NPI:1750375770
Name:CROSSROADS PHYSICIAN CORP
Entity type:Organization
Organization Name:CROSSROADS PHYSICIAN CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:320 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1313
Mailing Address - Country:US
Mailing Address - Phone:618-439-6370
Mailing Address - Fax:618-439-6490
Practice Address - Street 1:320 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1313
Practice Address - Country:US
Practice Address - Phone:618-439-6370
Practice Address - Fax:618-439-6490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSROADS PHYSICIAN CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-06
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL599560Medicare PIN
IL208459Medicare PIN