1043275142 NPI number — DR. PATRICK KOMESHAK DC

Table of content: DR. PATRICK KOMESHAK DC (NPI 1043275142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043275142 NPI number — DR. PATRICK KOMESHAK DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMESHAK
Provider First Name:
PATRICK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1043275142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 PARK PL STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWANSEA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62226-2965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-236-3600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 PARK PL STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SWANSEA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62226-2965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-236-3600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2006

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: 111N00000X , with the licence number:  038008047 , 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: 08221308 . This is a "BCBS ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: U66933 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 104259 . This is a "GHP GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 375120 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 038008047 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 371371791 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4400415 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: DD4196 . This is a "MEDICARE RAILROAD GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 104260 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7083136 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111586 . This is a "BCBS MISSOURI" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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