Provider Demographics
NPI:1760688642
Name:ATWOOD MEDICAL, LLC
Entity type:Organization
Organization Name:ATWOOD MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-395-1400
Mailing Address - Street 1:1400 N EAST ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2426
Mailing Address - Country:US
Mailing Address - Phone:618-395-1400
Mailing Address - Fax:618-395-1405
Practice Address - Street 1:1400 N EAST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2426
Practice Address - Country:US
Practice Address - Phone:618-395-1400
Practice Address - Fax:618-395-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-110096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL332782580Medicaid
IL332782580Medicaid
IL1235182809Medicare PIN