NPIMap

Individual provider Active NPI

Robert J Davidson, M.D.

  • Family Medicine Physician
  • Pinckneyville, IL
National Provider Identifier
1790774826
Registry record updated Dec 20, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
36-079086 Issued in IL
Practice address
13 N Walnut St
Pinckneyville, IL 62274-1050
Phone
(618) 357-2147
Fax
(618) 357-8142
NPI assigned
Oct 20, 2005
Last updated
Dec 20, 2013By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Dec 20, 2013

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 36-079086 IL Primary

Addresses

Primary practice location

13 N Walnut St
Pinckneyville, IL 62274-1050

Mailing address

3702 Shoshone Cir
Pinckneyville, IL 62274-4113
Phone (618) 357-2147

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20070823000929 IL Practitioner - Family PracticePractitioner - Emergency Medicine 0244322097 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
State University of New York - State College Optometry, 1979
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

900 N Washington St
Du Quoin, IL 62832-1230

900 N Washington St
Du Quoin, IL 62832-1233
Phone (618) 542-2146

PO Box
Suite 192
Du Quoin, IL 62832-0192

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled
HHS exclusion list flag
CMS’s directory marks this NPI as on an HHS exclusion list; no matching OIG record was found. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
36-079086ILMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Marshall Browning Hospital Association CurrentSince Jan 28, 2019 Accepting new patients
Marshall Browning Hospital Association CurrentSince Jan 28, 2019 Accepting new patients
Marshall Browning Hospital Association PastSince Apr 20, 2025 Accepting new patients
Fairview Rehabilitation & Healthcare LLC PastSince Jan 1, 2021 Accepting new patients

Locations

900 N Washington St
Du Quoin, IL 62832
Phone (618) 542-1050

Interoperability endpoints

  • Direct secure messaging: robert.davidson.1@16246.direct.athenahealth.com
  • Direct secure messaging: robert.davidson@mbhdq.medalliesdirect.net

Ownership & related parties

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Friendship Manor Health CareNashville, IL, CCN 146043 Skilled nursing facility Operational/Managerial Control
Adp of the SNF		 Jan 1, 2018
Jan 1, 2018
Pinckneyville Nursing & Rehabilitation Center LLCPinckneyville, IL, CCN 146175 Skilled nursing facility Contracted Managing Employee Feb 1, 2017
Fairview Rehabilitation & HealthcareDu Quoin, IL, CCN 146032 Skilled nursing facility Contracted Managing Employee Jan 1, 2021

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 9

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1129766400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1387497600000",
    "number": "1790774826",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3702 SHOSHONE CIR",
            "city": "PINCKNEYVILLE",
            "state": "IL",
            "postal_code": "622744113",
            "telephone_number": "618-357-2147",
            "fax_number": "618-357-8142"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13 N WALNUT ST",
            "city": "PINCKNEYVILLE",
            "state": "IL",
            "postal_code": "622741050",
            "telephone_number": "618-357-2147",
            "fax_number": "618-357-8142"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DAVIDSON",
        "first_name": "ROBERT",
        "middle_name": "J",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-10-20",
        "last_updated": "2013-12-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "36-079086",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pinckneyville, IL

Sources for this page

Verify at the official NPI Registry.