1619981081 NPI number — MR. WILLIAM O WORTHINGTON PT

Table of content: MR. WILLIAM O WORTHINGTON PT (NPI 1619981081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619981081 NPI number — MR. WILLIAM O WORTHINGTON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WORTHINGTON
Provider First Name:
WILLIAM
Provider Middle Name:
O
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1619981081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHALL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-826-2365
Provider Business Mailing Address Fax Number:
217-826-8120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 N SECOND STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSHALL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-826-2365
Provider Business Practice Location Address Fax Number:
217-826-8120
Provider Enumeration Date:
07/28/2006

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: 225100000X , with the licence number:  070010429 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 05005753A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00397106 . This is a "RAILROAD UPIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1232012 . This is a "BLUE CROSS KINETIC 2010" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 080647 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 010934666 . This is a "KINETIC TAX ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com