Provider Demographics
NPI:1558665596
Name:CENTRAL ILLINOIS FAMILY PRACTICE
Entity type:Organization
Organization Name:CENTRAL ILLINOIS FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:II
Authorized Official - Credentials:FNP
Authorized Official - Phone:217-213-5254
Mailing Address - Street 1:603 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4320
Mailing Address - Country:US
Mailing Address - Phone:217-213-5254
Mailing Address - Fax:217-213-5240
Practice Address - Street 1:603 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4320
Practice Address - Country:US
Practice Address - Phone:217-213-5254
Practice Address - Fax:217-213-5240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003483041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty