1831240027 NPI number — TRACEY J REIMER P. T.

Table of content: TRACEY J REIMER P. T. (NPI 1831240027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831240027 NPI number — TRACEY J REIMER P. T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REIMER
Provider First Name:
TRACEY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P. T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REIMER
Provider Other First Name:
TRACEY
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831240027
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6000 N ALLEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-3294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-691-1400
Provider Business Mailing Address Fax Number:
309-693-3197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2351 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEKIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61554-3972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-353-5940
Provider Business Practice Location Address Fax Number:
309-353-1654
Provider Enumeration Date:
01/15/2007

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:  070012581 , 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: 0029040315 . This is a "IL BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 11373584 . This is a "CAQH PROVIDER ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00094223 . This is a "RAILROAD PIN NUMBER" identifier . This identifiers is of the category "OTHER".




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