Provider Demographics
NPI:1144432790
Name:STREATOR MEDICAL SERVICES, PC
Entity type:Organization
Organization Name:STREATOR MEDICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:RNC
Authorized Official - Phone:815-672-5500
Mailing Address - Street 1:409 E BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2915
Mailing Address - Country:US
Mailing Address - Phone:815-672-5500
Mailing Address - Fax:815-673-5522
Practice Address - Street 1:409 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2915
Practice Address - Country:US
Practice Address - Phone:815-672-5500
Practice Address - Fax:815-673-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
397240Medicare ID - Type Unspecified