1891842464 NPI number — SUSAN M PENNER OD

Table of content: SUSAN M PENNER OD (NPI 1891842464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891842464 NPI number — SUSAN M PENNER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENNER
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1891842464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
134 E BLACKHAWK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BYRON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61010-8610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-234-2020
Provider Business Mailing Address Fax Number:
815-234-7070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
134 E BLACKHAWK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BYRON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-234-2020
Provider Business Practice Location Address Fax Number:
815-234-7070
Provider Enumeration Date:
01/04/2007

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: 152W00000X , with the licence number:  046-008009 , 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: L08182 . This is a "PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 046-008009 . This is a "OPTOMETRY LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 4515286 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 7184011 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CL7273 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 410033446 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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