Provider Demographics
NPI:1366779282
Name:PHYSICIANS GROUP ASSOCIATES SC
Entity type:Organization
Organization Name:PHYSICIANS GROUP ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-698-9722
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-0500
Mailing Address - Country:US
Mailing Address - Phone:217-670-2424
Mailing Address - Fax:217-670-2809
Practice Address - Street 1:111 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:IL
Practice Address - Zip Code:62670-4593
Practice Address - Country:US
Practice Address - Phone:217-488-2201
Practice Address - Fax:217-488-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-13
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064159207Q00000X
IL209-003289363LF0000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL148925Medicare Oscar/Certification
IL233260Medicare PIN