Provider Demographics
NPI:1730375593
Name:KEWANEE MEDICAL CLINIC
Entity type:Organization
Organization Name:KEWANEE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:LINDBOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-853-5360
Mailing Address - Street 1:204 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-3661
Mailing Address - Country:US
Mailing Address - Phone:309-853-5360
Mailing Address - Fax:309-853-5106
Practice Address - Street 1:204 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-3661
Practice Address - Country:US
Practice Address - Phone:309-853-5360
Practice Address - Fax:309-853-5106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098462Medicaid
IL215694Medicare PIN
IL036098462Medicaid