Provider Demographics
NPI:1699962498
Name:ROBERT D CHILDERS MD SC
Entity type:Organization
Organization Name:ROBERT D CHILDERS MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DUNCAN
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-498-8470
Mailing Address - Street 1:400 MAPLE SUMMIT RD
Mailing Address - Street 2:STE 300
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2028
Mailing Address - Country:US
Mailing Address - Phone:618-498-8470
Mailing Address - Fax:618-498-8488
Practice Address - Street 1:400 MAPLE SUMMIT RD
Practice Address - Street 2:STE 300
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2028
Practice Address - Country:US
Practice Address - Phone:618-498-8470
Practice Address - Fax:618-498-8488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG2287OtherRAILROAD MEDICARE
IL208069Medicare PIN
DG2287OtherRAILROAD MEDICARE