Provider Demographics
NPI:1366705113
Name:ADAMS ENTERPRISES OF EAST CENTRAL ILLINOIS PC
Entity type:Organization
Organization Name:ADAMS ENTERPRISES OF EAST CENTRAL ILLINOIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GAY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-762-8576
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-0235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1109 N STATE ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1175
Practice Address - Country:US
Practice Address - Phone:217-762-8576
Practice Address - Fax:217-762-8578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007231261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07423137OtherBLUE SHIELD
IL533710Medicare PIN
IL07423137OtherBLUE SHIELD