Provider Demographics
NPI:1154719177
Name:SPRINGFIELD CLINIC MACOMB LAB
Entity type:Organization
Organization Name:SPRINGFIELD CLINIC MACOMB LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NERONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-528-7541
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:505 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3394
Practice Address - Country:US
Practice Address - Phone:309-833-1733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPRINGFIELD CLINIC, LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-29
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0702013291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D0702013OtherCLIA