1821166059 NPI number — JASON W OEHLER

Table of content: JASON W OEHLER (NPI 1821166059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821166059 NPI number — JASON W OEHLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OEHLER
Provider First Name:
JASON
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1821166059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 DEERFIELD RD
Provider Second Line Business Mailing Address:
SUITE 100 PMB 418
Provider Business Mailing Address City Name:
DEERFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60015-3241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-681-7888
Provider Business Mailing Address Fax Number:
708-681-7327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
675 W NORTH AVE
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
MELROSE PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60160-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-681-7888
Provider Business Practice Location Address Fax Number:
708-681-7327
Provider Enumeration Date:
12/04/2006

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: 363AM0700X , with the licence number:  085002383 , 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: 085002383 . This is a "STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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