Provider Demographics
NPI:1801920889
Name:FAMILY MEDICINE OF MCLEANSBORO LLC
Entity type:Organization
Organization Name:FAMILY MEDICINE OF MCLEANSBORO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:618-927-8714
Mailing Address - Street 1:208 SOUTH WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:MCLEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859
Mailing Address - Country:US
Mailing Address - Phone:618-643-2835
Mailing Address - Fax:618-643-2891
Practice Address - Street 1:208 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MCLEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1139
Practice Address - Country:US
Practice Address - Phone:618-643-2835
Practice Address - Fax:618-643-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty