1598725103 NPI number — PSG SERVICES, LLC

Table of content: (NPI 1598725103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598725103 NPI number — PSG SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSG SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DBA INTERIM HEALTHCARE
Provider Other Organization Name Type Code:
3
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:
1598725103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12855 S CICERO AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ALSIP
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60803-3043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-422-2934
Provider Business Mailing Address Fax Number:
708-422-5528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12855 S CICERO AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ALSIP
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60803-3043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-422-2934
Provider Business Practice Location Address Fax Number:
708-422-5528
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BULGER
Authorized Official First Name:
BERNARD
Authorized Official Middle Name:
D
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
708-422-2934

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1010247 , 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: N306219 . This is a "WELLCARE PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5215621 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2154 . This is a "PROF BUSINESS ADM" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 50180 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 000002649 . This is a "HUMANA PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 37144249001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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