1124285028 NPI number — GABRIELS PRIDE PEDIATRICS

Table of content: (NPI 1124285028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124285028 NPI number — GABRIELS PRIDE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GABRIELS PRIDE PEDIATRICS
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:
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:
1124285028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1337 PARK PLAZA DRIVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
OFALLON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62269-1777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-624-7391
Provider Business Mailing Address Fax Number:
618-624-7392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1337 PARK PLAZA DRIVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
OFALLON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62269-1777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-624-7391
Provider Business Practice Location Address Fax Number:
618-624-7392
Provider Enumeration Date:
05/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEVVAULH
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
EDMUND
Authorized Official Title or Position:
MD PRESIDENT OWNER
Authorized Official Telephone Number:
618-624-7391

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  036095488 , 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: 036095488 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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