PASSAVANT PHYSICIAN ASSOCIATION (NPI# 1962689307) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1962689307 |
| Entity Type | Organization |
| Organization Name | PASSAVANT PHYSICIAN ASSOCIATION |
| Practice Address |
1600 W Walnut St Jacksonville IL 62650-1136 |
| Practice Telephone | 2174795890 |
| Practice Fax Number | 2172432206 |
| Mailing Telephone | 2174795890 |
| Mailing Fax Number | 2174795677 |
| Enumeration Date | 2008-01-29 |
| Last Update Date | 2018-03-21 |
| Authorized Official Name | MRS. WENDI D GRAHAM (PRACTICE PLAN ADMINISTRATOR) |
| Authorized Official Telephone | 2174795663 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 207Q00000X | Family Medicine | Allopathic & Osteopathic Physicians | ||
| N | 208600000X | Surgery | Allopathic & Osteopathic Physicians | ||
| N | 207R00000X | Internal Medicine | Allopathic & Osteopathic Physicians | ||
| N | 207VX0000X |
Obstetrics & Gynecology Specialization: Obstetrics |
036048526 | IL | Allopathic & Osteopathic Physicians |
| N | 207Y00000X | Otolaryngology | 036057937 | IL | Allopathic & Osteopathic Physicians |
| N | 2083P0011X |
Preventive Medicine Specialization: Undersea and Hyperbaric Medicine |
Allopathic & Osteopathic Physicians | ||
| N | 231H00000X | Audiologist | Speech, Language and Hearing Service Providers | ||
| N | 363LA2200X |
Nurse Practitioner Specialization: Adult Health |
Physician Assistants & Advanced Practice Nursing Providers | ||
| Y | 261QM1300X |
Clinic/Center Specialization: Multi-Specialty |
Ambulatory Health Care Facilities |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| IL | BCBS | 6932023 | 01 |
| IL | RAILROAD PTAN | DH1383 | 01 |
| IL | 2ND LOCATION MEDICARE PIN # | IL2621 | 01 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1205387958 | Passavant Physician Association | Obstetrics & Gynecology | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2016-10-18 |
| 1972054609 | Passavant Physician Association | Family Medicine | 559 N Westgate Ave, Jacksonville, IL 62650-1156 | 2016-10-18 |
| 1922410836 | Passavant Physician Association | Clinic/Center | 557 N Westgate Ave, Jacksonville, IL 62650-1156 | 2014-05-27 |
| 1841578507 | Passavant Physician Association | Nurse Practitioner | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2011-07-29 |
| 1720370778 | Passavant Physician Association | Internal Medicine | 559 N Westgate Ave, Jacksonville, IL 62650-1156 | 2011-05-10 |
| Street Address |
1600 W WALNUT ST |
| City | JACKSONVILLE |
| State | IL |
| Zip Code | 62650-1136 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1609873249 | Charles Milton Sheaff | Surgery | 1600 W Walnut St, East Wing 2nd Floor, Jacksonville, IL 62650-1136 | 2005-06-28 |
| 1528690799 | Holly Diane Pennell | Nurse Practitioner | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2020-02-06 |
| 1669004081 | Elizabeth Ann Johnson | Nurse Practitioner | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2020-02-05 |
| 1164053526 | Kayla Christine Vickers | Physical Therapist | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2020-02-03 |
| 1366912040 | Kelsi Lynn Dobson | Social Worker | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2018-11-26 |
| 1114402518 | Michelle Lee Geiss | Nurse Practitioner | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2018-10-02 |
| 1134606858 | Matthew Pulley | Nurse Practitioner | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2018-07-25 |
| 1760994040 | Passavant Memorial Area Hospital Association | Family Medicine | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2017-10-26 |
| 1871002238 | Courtney Howell | Social Worker | 1600 W Walnut St, Jacksonville, IL 62650-1136 | 2017-09-28 |
| 1831639194 | Carrie Elizabeth Janus | Nurse Practitioner | 1600 W Walnut St, The Center for Psychiatric Health, Jacksonville, IL 62650-1136 | 2017-03-06 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1134768708 | Stephanie Lee Mabus | Occupational Therapy Assistant | 873 Gorve St, Jacksonville, IL 62650 | 2019-12-31 |
| 1285281071 | Sharshon Pharmacy Inc | Pharmacy | 154 W Morton Ave, Jacksonville, IL 62650 | 2019-08-26 |
| 1992275499 | Brittany Ruth Helmich | Counselor | 340 W. State St., Jacksonville, IL 62650 | 2018-11-28 |
| 1811391782 | Rodney E. Overstreet | Hearing Instrument Specialist | 1521 W. Walnut, Jacksonville, IL 62650 | 2014-10-21 |
| 1407979818 | Jan Ala | Speech-Language Pathologist | 1111 W Morton, Speechworks, Jacksonville, IL 62650 | 2007-04-09 |
| 1083787592 | Eldon G Barrowes Dds & Assoc PC | Dentist | 1515 West Walnut, Bldg #3, Jacksonville, IL 62650 | 2006-11-15 |
| 1194895979 | Joseph J Kozma | Internal Medicine | 1440 West Walnut, Jacksonville, IL 62650 | 2006-11-08 |
| 1740350529 | Susan Weller | Dentist | 1614 West Lafayette Avenue, Jackson, IL 62650 | 2006-11-08 |
| 1659467793 | Shawn M Fry | Family Medicine | 610 N. Westgate, Jacksonville, IL 62650 | 2006-10-05 |
| 1518050061 | Ward Richard Dunseth II | Nurse Anesthetist, Certified Registered | 1400 W Walnut, Jacksonville, IL 62650 | 2006-10-02 |
| Find all providers in zip 62650 | ||||
| Taxonomy Code | 261QM1300X |
| Grouping | Ambulatory Health Care Facilities |
| Classification | Clinic/Center |
| Specialization | Multi-Specialty |
| Definition to come... |
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| 1851344378 | Solantic/south Florida, LLC | Clinic/Center | 8711 Perimter Park Blvd., Suite 6, Jacksonville, FL 32216 | 2006-05-18 |
| 1255336350 | Walter R Gilbert Jr Md Pa | Clinic/Center | 3 Shircliff Way, Ste 122, Jacksonville, FL 32204-4757 | 2005-06-15 |
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| 1801407291 | Patient Focus Physicians Associates Inc | Clinic/Center | 101 Century 21 Dr, Jacksonville, FL 32216-8115 | 2020-08-11 |
| 1093331456 | Jax Health LLC | Clinic/Center | 4540 Southside Blvd Ste 401, Jacksonville, FL 32216-5488 | 2020-06-22 |
| Find all providers in JACKSONVILLE | ||||
| City | JACKSONVILLE |
| Zip Code | 62650 |
Please comment or provide details below to improve the information on PASSAVANT PHYSICIAN ASSOCIATION.
| 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.