1063578854 NPI number — MACKIE A SNEBOLD DO

Table of content: MACKIE A SNEBOLD DO (NPI 1063578854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063578854 NPI number — MACKIE A SNEBOLD DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SNEBOLD
Provider First Name:
MACKIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOKKELENBURG
Provider Other First Name:
MACKIE
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1063578854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3920 N JOHNSBURG RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60051-6320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-344-0088
Provider Business Mailing Address Fax Number:
815-363-3477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3920 N JOHNSBURG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60051-6320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-344-0088
Provider Business Practice Location Address Fax Number:
815-363-3477
Provider Enumeration Date:
12/28/2006

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: 207Q00000X , with the licence number:  036067812 , 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: 0360678124 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05615148 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".