1669616983 NPI number — ILLINOIS STATE UNIVERSITY

Table of content: (NPI 1669616983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669616983 NPI number — ILLINOIS STATE UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS STATE UNIVERSITY
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:
SPEECH & HEARING CLINIC
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:
1669616983
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 S UNIVERSITY ST
Provider Second Line Business Mailing Address:
CAMPUS BOX 4720
Provider Business Mailing Address City Name:
NORMAL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61790-4720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-438-8641
Provider Business Mailing Address Fax Number:
309-438-0575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 S UNIVERSITY ST
Provider Second Line Business Practice Location Address:
CAMPUS BOX 4720
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61790-4720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-438-8641
Provider Business Practice Location Address Fax Number:
309-438-0575
Provider Enumeration Date:
04/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VERTICCHIO
Authorized Official First Name:
HEIDI
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
309-438-3266

Provider Taxonomy Codes

  • Taxonomy code: 237600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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