Crossroads Physician Corp

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

Legal business name

CROSSROADS PHYSICIAN CORP

Practice address

3505 Broadway St
Mount Vernon, IL 62864-2202

Phone

(618) 241-8772

Fax

(618) 241-8775

NPI assigned

Sep 6, 2005

Organization subpart

Yes

Parent organization

CROSSROADS PHYSICIAN CORPAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Debbie Brewer

Title

Director of Provider Enrollment

Phone

(615) 465-7626

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Crossroads Family Medicine of Mt Vernon Doing business as

Part of

Crossroads Physicians C

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1125964800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1312934400000",
    "number": "1669466686",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 689022",
            "city": "FRANKLIN",
            "state": "TN",
            "postal_code": "370689022",
            "telephone_number": "615-465-7626"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3505 BROADWAY ST",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628642202",
            "telephone_number": "618-241-8772",
            "fax_number": "618-241-8775"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CROSSROADS PHYSICIAN CORP",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CROSSROADS PHYSICIAN CORP",
        "enumeration_date": "2005-09-06",
        "last_updated": "2011-08-10",
        "status": "A",
        "authorized_official_last_name": "BREWER",
        "authorized_official_first_name": "DEBBIE",
        "authorized_official_title_or_position": "DIRECTOR OF PROVIDER ENROLLMENT",
        "authorized_official_telephone_number": "615-465-7626"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036041176",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crossroads Family Medicine of Mt Vernon",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Carrie Caroline Crocker, MSW, LCSW
• Melanie Cross, FNP
• Crossroads Home Care Services, LLC
• Crossroads Physician Corp
• Crossroads Physician Corp
• Crossroads Physician Corp
• Crossroads Physician Corp
• Crossroads Physician Corp
• Crossroads Physician Corp
• Crossroads Physician Corp

• Rural Health Clinic/Center in Mount Vernon, IL
• Providers in Mount Vernon, IL by specialty
• Rural Health Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 10, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.