1114037173 NPI number — KIMBERLY SCHAUMBURG PT

Table of content: KIMBERLY SCHAUMBURG PT (NPI 1114037173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114037173 NPI number — KIMBERLY SCHAUMBURG PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHAUMBURG
Provider First Name:
KIMBERLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUIZENGA
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114037173
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:
630-759-9510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 KANEVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GENEVA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60134-2578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-584-1411
Provider Business Practice Location Address Fax Number:
630-513-2630
Provider Enumeration Date:
08/30/2006

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: 225100000X , with the licence number:  070013680 , 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: 070013680 . This is a "STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: K30311 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: CF2064 . This is a "RAILROAD GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 753210 . This is a "MEDICARE GROUP" identifier . This identifiers is of the category "OTHER".




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