Provider Demographics
NPI:1174763171
Name:MED EAST SC
Entity type:Organization
Organization Name:MED EAST SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-874-5016
Mailing Address - Street 1:100 E VANDALIA ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-1703
Mailing Address - Country:US
Mailing Address - Phone:618-792-6496
Mailing Address - Fax:
Practice Address - Street 1:129 N 8TH ST
Practice Address - Street 2:SUITE 228
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-2917
Practice Address - Country:US
Practice Address - Phone:618-874-5016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty