NPIMap

Impact Physician Group, Illinois LLC

Organization Active NPI Internal Medicine Physician · Plano, IL

NPI 1467920124 · NPPES record last updated Dec 19, 2022

Key facts

NPI
1467920124
Entity type
Organization (NPI type 2)
Primary specialty
Internal Medicine Physician 207R00000X
Legal business name
IMPACT PHYSICIAN GROUP, ILLINOIS LLC
Practice address
115 E South St Ste F
Plano, IL 60545-1595
Phone
(630) 552-7166
NPI assigned
Nov 10, 2018
Organization subpart
No

Authorized official

Name
Mr. Paul Miller
Title
Ceo
Phone
(678) 967-5599

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Medicare participation

Medicare fee-for-service enrollment
Enrolled in IL

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20181231000524 IL Part B Supplier - Clinic/Group Practice 3870838428 Receives reassigned benefits from 12 practitioners
Practice locations: Edwardsville, IL; Woodridge, IL; Plano, IL

National Provider Directory

Locations

3402 Anderson Healthcare Dr
Edwardsville, IL 62025
Phone (618) 307-7900

2920 Leverenz Rd
Naperville, IL 60564
Phone (630) 359-8835

1041 Station Dr
Ste B7
Oswego, IL 60543
Phone (630) 551-3666

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 207R00000X Yes
Endocrinology, Diabetes & Metabolism Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 207RE0101X
Gastroenterology Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 207RG0100X
Pulmonary Disease Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 207RP1001X

Addresses

Primary practice location

115 E South St Ste F
Plano, IL 60545-1595

Mailing address

21 Eastbrook BND Ste 218
Peachtree City, GA 30269-1546
Phone (678) 967-5599

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Dec 19, 2022.

{
    "created_epoch": "1541808000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1671408000000",
    "number": "1467920124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21 EASTBROOK BND STE 218",
            "city": "PEACHTREE CITY",
            "state": "GA",
            "postal_code": "302691546",
            "telephone_number": "678-967-5599"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 E SOUTH ST STE F",
            "city": "PLANO",
            "state": "IL",
            "postal_code": "605451595",
            "telephone_number": "630-552-7166"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPACT PHYSICIAN GROUP, ILLINOIS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-11-10",
        "last_updated": "2022-12-19",
        "certification_date": "2022-12-19",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "678-967-5599",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207RE0101X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Endocrinology, Diabetes & Metabolism",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RG0100X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Gastroenterology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Plano, IL

All providers in Plano, IL · Internal Medicine Physician in Illinois

Sources for this page

Verify at the official NPI Registry.