KING CITY PHYSICIAN COMPANY, LLC (NPI# 1134470859) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1134470859 |
| Entity Type | Organization |
| Organization Name | KING CITY PHYSICIAN COMPANY, LLC |
| Practice Address |
4117 S Water Tower Pl Suite C Mount Vernon IL 62864-6567 |
| Practice Telephone | 6182420672 |
| Practice Fax Number | 6182420862 |
| Mailing Telephone | 6182420672 |
| Mailing Fax Number | 6182420862 |
| Enumeration Date | 2012-09-20 |
| Last Update Date | 2012-10-04 |
| Authorized Official Name | BRIAN PEOPLES (VICE PRESIDENT) |
| Authorized Official Telephone | 6154657585 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 207Q00000X | Family Medicine | Allopathic & Osteopathic Physicians | ||
| N | 207R00000X | Internal Medicine | Allopathic & Osteopathic Physicians | ||
| N | 207RC0000X |
Internal Medicine Specialization: Cardiovascular Disease |
Allopathic & Osteopathic Physicians | ||
| N | 207RP1001X |
Internal Medicine Specialization: Pulmonary Disease |
Allopathic & Osteopathic Physicians | ||
| N | 2080A0000X |
Pediatrics Specialization: Adolescent Medicine |
Allopathic & Osteopathic Physicians | ||
| N | 208600000X | Surgery | Allopathic & Osteopathic Physicians | ||
| N | 208800000X | Urology | Allopathic & Osteopathic Physicians | ||
| N | 363A00000X | Physician Assistant | Physician Assistants & Advanced Practice Nursing Providers | ||
| N | 363LF0000X |
Nurse Practitioner Specialization: Family |
Physician Assistants & Advanced Practice Nursing Providers | ||
| Y | 207YX0007X |
Otolaryngology Specialization: Plastic Surgery within the Head & Neck |
Allopathic & Osteopathic Physicians |
| Street Address |
4117 S WATER TOWER PL SUITE C |
| City | MOUNT VERNON |
| State | IL |
| Zip Code | 62864-6567 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1720057730 | Heartland Occupational Medicine Physicians of Illinois S C | Family Medicine | 4117 S Water Tower Pl, Suite D, Mount Vernon, IL 62864-6293 | 2006-03-14 |
| 1679979157 | Michael Murray | Physician Assistant | 4117 S Water Tower Pl, Suite D, Mount Vernon, IL 62864-6567 | 2014-11-12 |
| 1821158833 | David J. Lane, Ltd. | Audiologist | 4117 S Water Tower Pl, Suite C, Mount Vernon, IL 62864-6293 | 2006-12-11 |
| 1063424836 | Nancy K Kertz | Nurse Practitioner | 4117 S Water Tower Pl, Suite D, Mount Vernon, IL 62864-6293 | 2006-08-12 |
| 1285650838 | Jacques Papazian M.d,s.c. | Otolaryngology | 4117 S Water Tower Pl, Suite C, Mount Vernon, IL 62864-6293 | 2006-07-15 |
| 1164472155 | David J Lane | Audiologist | 4117 S Water Tower Pl, Suite C, Mount Vernon, IL 62864-6293 | 2006-05-11 |
| 1366491193 | Jacques Papazian | Family Medicine | 4117 S Water Tower Pl, Suite C, Mount Vernon, IL 62864-6293 | 2006-05-09 |
| 1053380683 | Charles W Neal | Family Medicine | 4117 S Water Tower Pl, Suite D, Mount Vernon, IL 62864-6293 | 2006-03-16 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1619438892 | Melissa Pryer | Dietitian, Registered | 2020 Broadway, Suite 1, Mt. Vernon, IL 62864 | 2019-03-28 |
| 1487145454 | Chiropractic Wellness Center of Mt Vernon, LLC. | Chiropractor | 1009 S 42nd St Ste 5, Mount Vernon, IL 62864 | 2018-05-24 |
| 1851889208 | Kimberly Tate | Counselor | 4110 North Water Place, Mt. Vernon, IL 62864 | 2018-05-01 |
| 1871907790 | University Hematology Oncology Inc | Specialist | #11 Cusumano Professional Plaza, Mount Vernon, IL 62864 | 2014-06-18 |
| 1457771677 | Dynamic Counseling and Consultation Services | Social Worker | 3600 S Water Tower Pl, Mt Vernon, IL 62864 | 2014-04-27 |
| 1619239431 | Judith C Morgan | Counselor | 16338 N Illinois Hwy 37, Mount Vernon, IL 62864 | 2012-06-08 |
| 1073888624 | James Brian Verges | Counselor | 16338 N. Illinois Hwy 37, Mount Vernon, IL 62864 | 2012-03-15 |
| 1720352271 | Lucinda M. Holdren | Counselor | 16338 North Illinois Highway 37, Mount Vernon, IL 62864 | 2012-03-01 |
| 1780978627 | Jamie M Orange | Physical Therapy Assistant | 19958 Fairfield Rd, Mt. Vernon, IL 62864 | 2011-06-08 |
| 1780978791 | Wendy Marie Claytor | Speech-Language Pathologist | 600 E Il Hwy 15, Mount Vernon, IL 62864 | 2011-06-07 |
| Find all providers in zip 62864 | ||||
| Taxonomy Code | 207YX0007X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Otolaryngology |
| Specialization | Plastic Surgery within the Head & Neck |
| An otolaryngologist with additional training in plastic and reconstructive procedures within the head, face, neck and associated structures, including cutaneous head and neck oncology and reconstruction, management of maxillofacial trauma, soft tissue repair and neural surgery. The field is diverse and involves a wide age range of patients, from the newborn to the aged. While both cosmetic and reconstructive surgeries are practiced, there are many additional procedures which interface with them. |
| Notes: Source: American Board of Medical Specialties, 2007. www.abms.org [7/1/2007: definiton added, source added] Additional Resources: American Board of Otolaryngology, 2007. http://www.aboto.org/. Board certification for Medical Doctors (MDs) is provided by the American Board of Otolaryngology. Board certification for Doctors of Osteopathy is currently provided in the subspecialty of Otolaryngology/Facial Plastic Surgery (see Taxonomy Code 207YX0905X) |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1558646745 | Peter Anthony Brusca | Otolaryngology | 1310 N Ritchie Ct, 29b, Chicago, IL 60610-2168 | 2011-10-19 |
| 1942310081 | Parkview Ear, Nose & Throat Clinic, S.c. | Otolaryngology | 112 Park Ridge Ln, Pekin, IL 61554-3900 | 2006-08-30 |
| 1295707578 | James Curtis Hertenstein | Otolaryngology | 8600 N State Rt 91, Ste 300, Peoria, IL 61615 | 2006-02-02 |
| 1720068695 | Fazlur R. Zahurullah | Otolaryngology | 3401 N Perryville Rd, Rockford, IL 61114-8011 | 2006-01-18 |
| 1982609103 | Gordon J Siegel | Otolaryngology | 3 E Huron St, Fl 1, Chicago, IL 60611-2887 | 2005-06-15 |
| 1467816918 | Smart Sinus and Allergy Florida LLC | Otolaryngology | 1100 E Woodfield Rd, Suite 140, Schaumburg, IL 60173-5116 | 2016-04-11 |
| 1962880419 | Richard Kao | Otolaryngology | 1611 W Harrison St, Chicago, IL 60612-4861 | 2015-05-15 |
| 1194163139 | Finn R. Amble, M.d. F.a.c.s., S.c | Otolaryngology | 1505 Eastland Dr, Suite 220, Bloomington, IL 61701-3534 | 2013-06-12 |
| 1861731689 | Hosseinali Jafari | Otolaryngology | 301 N 8th St, Springfield, IL 62701-1041 | 2013-02-14 |
| 1467601583 | Muthuswamy Dhiwakar | Otolaryngology | 301 N 8th St, Springfield, IL 62701-1041 | 2008-09-12 |
| Find all providers with the same taxonomy | ||||
| City | MOUNT VERNON |
| Zip Code | 62864 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.