Provider Demographics
NPI:1679261358
Name:MEDGENYX, PLLC
Entity type:Organization
Organization Name:MEDGENYX, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-778-8505
Mailing Address - Street 1:907 W MARKETVIEW DR STE 10
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1250
Mailing Address - Country:US
Mailing Address - Phone:217-778-8505
Mailing Address - Fax:
Practice Address - Street 1:1734 S STONE CREEK BLVD
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-9667
Practice Address - Country:US
Practice Address - Phone:217-390-0273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service