NPIMap

Organization Active NPI

Passavant Physician Association

  • Multi-Specialty Clinic/Center
  • Jacksonville, IL
National Provider Identifier
1962689307
Registry record updated Mar 21, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
PASSAVANT PHYSICIAN ASSOCIATION
Practice address
1600 W Walnut St
Jacksonville, IL 62650-1136
Phone
(217) 479-5890
Fax
(217) 243-2206
NPI assigned
Jan 29, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 21, 2018

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

Authorized official

Name
Mrs. Wendi D Graham
Title
Practice Plan Administrator
Phone
(217) 479-5663

Specialties & licenses 9

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Obstetrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207VX0000X 036048526 IL
Otolaryngology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Y00000X 036057937 IL
Undersea and Hyperbaric Medicine (Preventive Medicine) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2083P0011X
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208600000X
AudiologistGroup: 193200000X MULTI-SPECIALTY GROUP 231H00000X
Multi-Specialty Clinic/Center 261QM1300X Primary
Adult Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LA2200X

Addresses

Primary practice location

1600 W Walnut St
Jacksonville, IL 62650-1136

Mailing address

1600 W Walnut St
Jacksonville, IL 62650-1136
Phone (217) 479-5890

Other identifiers 3

IdentifierTypeStateIssuer
6932023OtherILBCBS
DH1383OtherILRAILROAD PTAN
IL2621OtherIL2ND LOCATION MEDICARE PIN #

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 5

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

NPI Registry JSON

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

{
    "created_epoch": "1201564800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1521590400000",
    "number": "1962689307",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1600 W WALNUT ST",
            "city": "JACKSONVILLE",
            "state": "IL",
            "postal_code": "626501136",
            "telephone_number": "217-479-5890",
            "fax_number": "217-479-5677"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1600 W WALNUT ST",
            "city": "JACKSONVILLE",
            "state": "IL",
            "postal_code": "626501136",
            "telephone_number": "217-479-5890",
            "fax_number": "217-243-2206"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PASSAVANT PHYSICIAN ASSOCIATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-01-29",
        "last_updated": "2018-03-21",
        "status": "A",
        "authorized_official_last_name": "GRAHAM",
        "authorized_official_first_name": "WENDI",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "PRACTICE PLAN ADMINISTRATOR",
        "authorized_official_telephone_number": "217-479-5663",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207VX0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology, Obstetrics",
            "state": "IL",
            "license": "036048526",
            "primary": false
        },
        {
            "code": "207Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology",
            "state": "IL",
            "license": "036057937",
            "primary": false
        },
        {
            "code": "2083P0011X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Preventive Medicine, Undersea and Hyperbaric Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "231H00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Audiologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LA2200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Adult Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "6932023",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD PTAN",
            "identifier": "DH1383",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "2ND LOCATION MEDICARE PIN #",
            "identifier": "IL2621",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 21, 2018; 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.