Crossroads Physician Corp
Internal Medicine in Mount Vernon, IL. Organization (NPI-2).
NPI number1790779874
StatusActive
Last updated in NPPESOct 30, 2007
Details
- NPI
- 1790779874
- Entity type
- Organization (NPI-2)
- Legal business name
- Crossroads Physician Corp
- Organization subpart
- Yes
- Enumeration date
- Sep 6, 2005
- Last updated
- Oct 30, 2007
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 207R00000X | Internal Medicine | – | IL | Yes |
| 363L00000X | Nurse Practitioner | – | IL |
Other names
- Crossroads Internal Medicine #1 (Doing Business As)
Practice location
4101 N Water Tower PlMount Vernon, IL 62864-6296
Phone 618-244-4313 · Fax 618-244-9592
Mailing address
4101 N Water Tower PlMount Vernon, IL 62864-6296
Phone 618-244-4313 · Fax 618-244-9592
Authorized official
Debbie T Brewer
Director Of Provider Enrollment
6154657626
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