1033158761 NPI number — MS. VICKI LYNN RUDH JONES P.T.

Table of content: MS. VICKI LYNN RUDH JONES P.T. (NPI 1033158761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033158761 NPI number — MS. VICKI LYNN RUDH JONES P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDH JONES
Provider First Name:
VICKI
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
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:
WILSON
Provider Other First Name:
VICKI
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033158761
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
283 OSPREY RDG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACHESNEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61115-8364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-623-9200
Provider Business Mailing Address Fax Number:
815-623-9200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
283 OSPREY RDG
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACHESNEY PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61115-8364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-623-9200
Provider Business Practice Location Address Fax Number:
815-623-9200
Provider Enumeration Date:
06/06/2006

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: 225100000X , with the licence number:  070010001 , 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: 10132018 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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