1164490066 NPI number — JAMES M PAPESCH MD

Table of content: JAMES M PAPESCH MD (NPI 1164490066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164490066 NPI number — JAMES M PAPESCH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAPESCH
Provider First Name:
JAMES
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1164490066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 S MILWAUKEE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-1080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-990-5398
Provider Business Mailing Address Fax Number:
630-645-6440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 S MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
CONDELL MEDICAL CENTER RADIOLOGY DEPARTMENT
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-3204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-362-2900
Provider Business Practice Location Address Fax Number:
847-990-5380
Provider Enumeration Date:
03/08/2006

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: 2085R0202X , with the licence number:  47867 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34636100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".