Provider Demographics
NPI:1194980516
Name:CROSSROADS PHYSICIAN CORP
Entity type:Organization
Organization Name:CROSSROADS PHYSICIAN CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:209 CROSSRODS PL
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6545
Mailing Address - Country:US
Mailing Address - Phone:618-241-7207
Mailing Address - Fax:
Practice Address - Street 1:209 CROSSROADS PL
Practice Address - Street 2:SUITE 140
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6545
Practice Address - Country:US
Practice Address - Phone:618-241-7207
Practice Address - Fax:618-241-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty