1265474118 NPI number — DR. TERESE J LAUGHLIN DPM

Table of content: DR. TERESE J LAUGHLIN DPM (NPI 1265474118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265474118 NPI number — DR. TERESE J LAUGHLIN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAUGHLIN
Provider First Name:
TERESE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1265474118
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 W WALNUT ST
Provider Second Line Business Mailing Address:
SUITE 12
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62650-1150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-243-1101
Provider Business Mailing Address Fax Number:
217-243-5003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 W WALNUT ST
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62650-1150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-243-1101
Provider Business Practice Location Address Fax Number:
217-243-5003
Provider Enumeration Date:
06/12/2006

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: 213ES0103X , with the licence number:  016004832 , 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: 016004832/4974780001 . This is a "MEDICARE DMERC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 034378 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 016004832 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06932011 . This is a "BCBS OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 330738/270056166 . This is a "HEALTHLINK PPO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00027606/DA1788 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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