Provider Demographics
NPI:1972054609
Name:PASSAVANT PHYSICIAN ASSOCIATION
Entity type:Organization
Organization Name:PASSAVANT PHYSICIAN ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-479-5890
Mailing Address - Street 1:559 N WESTGATE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1156
Mailing Address - Country:US
Mailing Address - Phone:217-243-5474
Mailing Address - Fax:217-245-2322
Practice Address - Street 1:559 N WESTGATE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1156
Practice Address - Country:US
Practice Address - Phone:217-243-5474
Practice Address - Fax:217-245-2322
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PASSAVANT MEMORIAL AREA HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-18
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty