Provider Demographics
NPI:1700065851
Name:SALEM FAMILY PRACTICE, SC
Entity type:Organization
Organization Name:SALEM FAMILY PRACTICE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:KESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-548-1330
Mailing Address - Street 1:1325 W WHITTAKER ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-2007
Mailing Address - Country:US
Mailing Address - Phone:618-740-0341
Mailing Address - Fax:618-740-0343
Practice Address - Street 1:1325 W WHITTAKER ST
Practice Address - Street 2:SUITE #3
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-2007
Practice Address - Country:US
Practice Address - Phone:618-740-0341
Practice Address - Fax:618-740-0343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD51909Medicare UPIN