1023027216 NPI number — GREGORY R POLOVICH

Table of content: GREGORY R POLOVICH (NPI 1023027216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023027216 NPI number — GREGORY R POLOVICH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLOVICH
Provider First Name:
GREGORY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023027216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
823 MESA VERDE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAYLORVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62568-9103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-824-6222
Provider Business Mailing Address Fax Number:
217-824-5511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 W SPRESSER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAYLORVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62568-1831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-824-6222
Provider Business Practice Location Address Fax Number:
217-824-5511
Provider Enumeration Date:
08/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038-004196 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8782001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".