1679686745 NPI number — DR. JAMES J PAVLOVICH M.D.

Table of content: DR. JAMES J PAVLOVICH M.D. (NPI 1679686745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679686745 NPI number — DR. JAMES J PAVLOVICH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAVLOVICH
Provider First Name:
JAMES
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
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:
1679686745
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 155
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHRISTOPHER
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62822-0155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-724-1624
Provider Business Mailing Address Fax Number:
618-724-4628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6294 STATE HIGHWAY 154
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SESSER
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-625-6979
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2006

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: 208000000X , with the licence number:  036089862 , 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: 324148 . This is a "GHP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 370007818 . This is a "RR MEDICARE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 3932056 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 48175 . This is a "GHP INSURANCE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 027538 . This is a "HAMP INSURANCE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036089862 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 271458 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 7210895 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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