Keri Douglas, FNP-BC
Individual provider Active NPI Nurse Practitioner · Centrailia, IL
NPI 1104201714 · NPPES record last updated Jul 24, 2015
Key facts
- NPI
- 1104201714
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Nurse Practitioner 363L00000X
- License
- 209.012941 (IL)
- Practice address
- 1054 M. L. King Drive #125
Centrailia, IL 62801 - Phone
- (618) 436-5200
- NPI assigned
- Jul 24, 2015
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150819008737 | IL | Practitioner - Nurse Practitioner | 0547575599 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 209.012941 | IL | MD | Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| St. Mary'S Hospital, Centralia, Illinois | Current |
Accepting new patients | |
| St. Mary'S Hospital, Centralia, Illinois | Current |
Accepting new patients | |
| Physician Services Corporation of Southern Illinois Inc. | Current |
Accepting new patients |
Locations
444 N Pleasant Ave
Centralia, IL 62801
Phone (618) 436-5665
400 N Pleasant Ave
Centralia, IL 62801
Phone (618) 436-5221
1054 Martin Luther King Dr
Ste 125
Centralia, IL 62801
Phone (618) 436-5200
7420 Solutions Ctr
Chicago, IL 60677
Phone (314) 989-3155
2 Good Samaritan Way
Ste 320
Mount Vernon, IL 62864
Phone (618) 899-1944
Interoperability endpoints
- keri.douglas@79171750068228.direct.elationemr.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nurse Practitioner | 363L00000X | 209.012941 | IL | Yes |
Addresses
Primary practice location
1054 M. L. King Drive #125
Centrailia, IL 62801
Mailing address
197 Westmore Drive
Aviston, IL 62216
Phone (618) 560-8797
Other providers in Centrailia, IL
All providers in Centrailia, IL · Nurse Practitioner in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 24, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.