1366435224 NPI number — DR. JESSE L VANLE M.D.

Table of content: DR. JESSE L VANLE M.D. (NPI 1366435224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366435224 NPI number — DR. JESSE L VANLE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANLE
Provider First Name:
JESSE
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1366435224
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1505 EASTLAND DR
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61701-7906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-662-5506
Provider Business Mailing Address Fax Number:
309-662-5443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 EASTLAND DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61701-7906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-662-5506
Provider Business Practice Location Address Fax Number:
309-662-5443
Provider Enumeration Date:
08/25/2005

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: 208G00000X , with the licence number:  036109293 , 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: 204597405 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2299329 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 37875 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: IL0106 . This is a "JOHN DEERE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036109293001 . This is a "OSF HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 084529 . This is a "HEALTH ALLIANCE PROVIDER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036109293 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05732036 . This is a "BLUE SHIELD GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 566399 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 37972 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 276560 . This is a "PERSONAL CARE" identifier . This identifiers is of the category "OTHER".




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