1114104502 NPI number — INTERNAL MEDICINE OF SPRINGFIELD, LLC

Table of content: (NPI 1114104502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114104502 NPI number — INTERNAL MEDICINE OF SPRINGFIELD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE OF SPRINGFIELD, LLC
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:
1114104502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1835 E HIGH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45505-5210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-323-8804
Provider Business Mailing Address Fax Number:
888-922-5090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1835 E HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45505-5210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-323-8804
Provider Business Practice Location Address Fax Number:
888-922-5090
Provider Enumeration Date:
01/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
IMAMURA
Authorized Official First Name:
YOICHI
Authorized Official Middle Name:
CHARLEY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
939-323-8804

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35070875 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110182531 . This is a "RR MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2025267 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 706669 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 110182531 . This is a "RAIL ROAD MEDICARE PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 101046 . This is a "BLACK LUNG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 34187577027 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 56969067500 . This is a "WORKERS COMP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000035503 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0403252 . This is a "UHC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 569690675009 . This is a "MEDICAL MUTUAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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