Provider Demographics
NPI:1730217662
Name:VINE ST CLINIC
Entity type:Organization
Organization Name:VINE ST CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-726-7300
Mailing Address - Street 1:3225 HEDLEY RD
Mailing Address - Street 2:PO BOX 13484
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6248
Mailing Address - Country:US
Mailing Address - Phone:217-726-7300
Mailing Address - Fax:217-726-5989
Practice Address - Street 1:3225 HEDLEY RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-6248
Practice Address - Country:US
Practice Address - Phone:217-726-7300
Practice Address - Fax:217-726-5989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACL5057OtherRAILROAD MEDICARE
IL08415473OtherBLUE CROSS BLUE SHIELD
GACL5057OtherRAILROAD MEDICARE