1104066398 NPI number — CENTRAL MEDICAL SPECIALISTS LLC

Table of content: (NPI 1104066398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104066398 NPI number — CENTRAL MEDICAL SPECIALISTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL MEDICAL SPECIALISTS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTRAL MEDICAL SPECIALISTS
Provider Other Organization Name Type Code:
3
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:
1104066398
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2715 N CENTRAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60639-1351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-326-6100
Provider Business Mailing Address Fax Number:
773-385-6890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2715 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60639-1351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-326-6100
Provider Business Practice Location Address Fax Number:
773-385-6890
Provider Enumeration Date:
02/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
OKEEFE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
312-326-6100

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0014X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1601972 . This is a "BLUE CROSS BLUE SHIELD OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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