1467489807 NPI number — TINA M ROZENE M.D.

Table of content: TINA M ROZENE M.D. (NPI 1467489807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467489807 NPI number — TINA M ROZENE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROZENE
Provider First Name:
TINA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHRADER
Provider Other First Name:
TINA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467489807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 S 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62703-2403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-528-7541
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 N MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EFFINGHAM
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62401-2003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-342-4151
Provider Business Practice Location Address Fax Number:
217-347-0108
Provider Enumeration Date:
06/28/2006

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: 207R00000X , with the licence number:  036094764 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 036094764 , 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: 036094764 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 054508 . This is a "HEALTH ALLIANCE #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2523659 . This is a "BC/BS #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 386900 . This is a "HEALTHLINK #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 370012295 . This is a "RAILROAD MEDICARE/PALMETTO GBA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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