Provider Demographics
NPI:1962428516
Name:JOHNSTON CITY MEDICAL CLINIC, S. C.
Entity type:Organization
Organization Name:JOHNSTON CITY MEDICAL CLINIC, S. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:JAVED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-983-6911
Mailing Address - Street 1:201 W BROADWAY BLVD
Mailing Address - Street 2:P. O. BOX 209
Mailing Address - City:JOHNSTON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62951-1427
Mailing Address - Country:US
Mailing Address - Phone:618-983-6911
Mailing Address - Fax:618-983-6913
Practice Address - Street 1:201 W BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSTON CITY
Practice Address - State:IL
Practice Address - Zip Code:62951-1427
Practice Address - Country:US
Practice Address - Phone:618-983-6911
Practice Address - Fax:618-983-6913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
143879AMedicare ID - Type UnspecifiedRURAL HEALTH MEDICARE