1225286412 NPI number — MSMC INVESTORS, LLC

Table of content: (NPI 1225286412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225286412 NPI number — MSMC INVESTORS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MSMC INVESTORS, 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:
D/B/A METRO SOUTH MEDICAL CENTER PHYSICIAN GROUP
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:
1225286412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2753
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60499-2753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-597-2000
Provider Business Mailing Address Fax Number:
708-824-4505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12935 GREGORY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUE ISLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60406-2428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-597-2000
Provider Business Practice Location Address Fax Number:
708-824-4505
Provider Enumeration Date:
09/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WCISLO
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICIAN DETAILER
Authorized Official Telephone Number:
708-597-2000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036099296 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 036106823 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036118421 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036123124 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036110076 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036117162 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036089662 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036116768 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036058336 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036044194 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036112780 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036065557 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036068845 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036045416 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: 209003023 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0001628587 . This is a "BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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