Provider Demographics
NPI:1801909700
Name:TRAVIS, EDWARD CLAY (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:CLAY
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N. WASHINGTON ST PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832
Mailing Address - Country:US
Mailing Address - Phone:618-534-8538
Mailing Address - Fax:
Practice Address - Street 1:900 N. WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832
Practice Address - Country:US
Practice Address - Phone:618-534-8538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL46473OtherGHP INSURANCE NUMBER
IL3932056OtherBCBS OF IL
IL029889OtherHAMP INSURANCE NUMBER
IL036086580Medicaid
IL370661218401Medicaid
IL7210895OtherAETNA
IL080129731OtherRR MEDICARE NUMBER
IL253437OtherHEALTHLINK INSURANCE NUMB
IL324151OtherGHP
IL253437OtherHEALTHLINK INSURANCE NUMB
ILF81183Medicare UPIN
IL143821Medicare Oscar/Certification
IL214881Medicare PIN