Provider Demographics
NPI:1063960870
Name:MID AMERICA EMERGENCY MEDICINE
Entity type:Organization
Organization Name:MID AMERICA EMERGENCY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MISS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:O'BRIEN
Authorized Official - Last Name:ATWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:618-530-1950
Mailing Address - Street 1:300 N PARK AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6401
Mailing Address - Country:US
Mailing Address - Phone:618-530-1950
Mailing Address - Fax:
Practice Address - Street 1:700 N FIRST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-788-3156
Practice Address - Fax:217-788-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005966282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital