1902064785 NPI number — SPRINGFIELD FAMILY PRACTICE LAB

Table of content: (NPI 1902064785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902064785 NPI number — SPRINGFIELD FAMILY PRACTICE LAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGFIELD FAMILY PRACTICE LAB
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1902064785
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 SOUTH 6TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62703-2403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-528-7541
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 CENTRE WEST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62704-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-528-7541
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NERONE
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VICE PRESIDENT & CFO
Authorized Official Telephone Number:
217-528-7541

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 14D0435733 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".