Provider Demographics
NPI:1982791240
Name:WEBER MEDICAL CLINIC LTD
Entity type:Organization
Organization Name:WEBER MEDICAL CLINIC LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-395-2223
Mailing Address - Street 1:1200 N EAST STREET
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2499
Mailing Address - Country:US
Mailing Address - Phone:618-395-8561
Mailing Address - Fax:618-395-8552
Practice Address - Street 1:1200 N EAST STREET
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2499
Practice Address - Country:US
Practice Address - Phone:618-395-8561
Practice Address - Fax:618-395-8552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5415423336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AW1615977OtherDEA
AW1615977OtherDEA
IL=========001Medicaid
294490Medicare ID - Type Unspecified
IL210225Medicare ID - Type Unspecified