1881759967 NPI number — MARK E UNZICKER CRNA

Table of content: MARK E UNZICKER CRNA (NPI 1881759967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881759967 NPI number — MARK E UNZICKER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UNZICKER
Provider First Name:
MARK
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1881759967
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 W. PARK ST.
Provider Second Line Business Mailing Address:
BWPC
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61801-2500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-383-6792
Provider Business Mailing Address Fax Number:
217-383-4752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 W. PARK ST.
Provider Second Line Business Practice Location Address:
ANESTHESIOLOGY
Provider Business Practice Location Address City Name:
URBANA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-383-3141
Provider Business Practice Location Address Fax Number:
217-383-3265
Provider Enumeration Date:
12/27/2006

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: 367500000X , with the licence number:  209000436 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 28119666A , 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)