Provider Demographics
NPI:1528059250
Name:GADSON CLINIC
Entity type:Organization
Organization Name:GADSON CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GADSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-223-7911
Mailing Address - Street 1:1622 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2817
Mailing Address - Country:US
Mailing Address - Phone:217-223-7911
Mailing Address - Fax:217-223-7941
Practice Address - Street 1:1622 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2817
Practice Address - Country:US
Practice Address - Phone:217-223-7911
Practice Address - Fax:217-223-7941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO16189OtherBLUE CROSS OF MISSOURI
IL018853OtherHEALTH ALLIANCE
IL076559OtherQHCM
IL120152OtherBLUE CROSS BLUE SHIELD
IL138989OtherHELATHLINK
IL018853OtherHEALTH ALLIANCE
ILA67896Medicare UPIN