Provider Demographics
NPI:1588732150
Name:NANCY J SHORT MD LLC
Entity type:Organization
Organization Name:NANCY J SHORT MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-792-6090
Mailing Address - Street 1:4360 KENNEDY DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4287
Mailing Address - Country:US
Mailing Address - Phone:309-792-6090
Mailing Address - Fax:309-792-6097
Practice Address - Street 1:4360 KENNEDY DR
Practice Address - Street 2:SUITE 1
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4287
Practice Address - Country:US
Practice Address - Phone:309-792-6090
Practice Address - Fax:309-792-6097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103076207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
L95020Medicare ID - Type Unspecified
F39391Medicare UPIN