| NPI | 1194913541 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TARA DEATON Administrator 618-993-3300 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 85003043) |
| Enumeration Date | 2007-10-11 |
| Last Update Date | 2007-10-11 |