1437263662 NPI number — THEODORE S. INGRASSIA III M.D.

Table of content: THEODORE S. INGRASSIA III M.D. (NPI 1437263662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437263662 NPI number — THEODORE S. INGRASSIA III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INGRASSIA
Provider First Name:
THEODORE
Provider Middle Name:
S.
Provider Name Prefix Text:
Provider Name Suffix Text:
III
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:
1437263662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 ROXBURY RD
Provider Second Line Business Mailing Address:
SUITE B600
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61107-5076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-397-7212
Provider Business Mailing Address Fax Number:
815-397-2539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 ROXBURY RD
Provider Second Line Business Practice Location Address:
SUITE B600
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61107-5076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-397-7212
Provider Business Practice Location Address Fax Number:
815-397-2539
Provider Enumeration Date:
08/17/2006

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: 207RP1001X , with the licence number:  036 083892 , 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: 101 00686 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036 083892 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110060997 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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