Provider Demographics
NPI:1912054891
Name:ST. CHARLES FAMILY MEDICAL CENTER, SC
Entity Type:Organization
Organization Name:ST. CHARLES FAMILY MEDICAL CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SCURLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-377-2800
Mailing Address - Street 1:110 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2526
Mailing Address - Country:US
Mailing Address - Phone:630-377-2800
Mailing Address - Fax:630-377-6774
Practice Address - Street 1:110 S 17TH ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2526
Practice Address - Country:US
Practice Address - Phone:630-377-2800
Practice Address - Fax:630-377-6774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03060113OtherSTATE LICENSE
IL667490OtherMEDICARE GROUP