1396880753 NPI number — DR. BENJAMIN SETH BUELTER D.C.

Table of content: DR. BENJAMIN SETH BUELTER D.C. (NPI 1396880753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396880753 NPI number — DR. BENJAMIN SETH BUELTER D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUELTER
Provider First Name:
BENJAMIN
Provider Middle Name:
SETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUELTER
Provider Other First Name:
BENJAMIN
Provider Other Middle Name:
SETH
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1396880753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4410 N KNOXVILLE AVE
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-6086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-282-6419
Provider Business Mailing Address Fax Number:
309-282-6003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4410 N KNOXVILLE AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-6086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-282-6419
Provider Business Practice Location Address Fax Number:
309-282-6003
Provider Enumeration Date:
02/21/2007

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: 111N00000X , with the licence number:  038-005718 , 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: 00007282057 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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