1114076528 NPI number — PEGGY LYNNE STEPHENS BC HIS

Table of content: PEGGY LYNNE STEPHENS BC HIS (NPI 1114076528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114076528 NPI number — PEGGY LYNNE STEPHENS BC HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEPHENS
Provider First Name:
PEGGY
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BC HIS
Provider Gender Code:
F

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:
1114076528
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 SHUMAN BLVD
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60563-8458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-303-5380
Provider Business Mailing Address Fax Number:
978-967-2732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2428 4TH ST SW
Provider Second Line Business Practice Location Address:
PLAZA WEST MALL
Provider Business Practice Location Address City Name:
MASON CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-424-1111
Provider Business Practice Location Address Fax Number:
641-424-6715
Provider Enumeration Date:
01/09/2007

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: 237700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0117044 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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