1174879340 NPI number — WHEATON MEDICAL SC

Table of content: (NPI 1174879340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174879340 NPI number — WHEATON MEDICAL SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHEATON MEDICAL SC
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:
6
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:
1174879340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 E SAINT CHARLES RD STE 204, 205, 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60188-3083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-480-7155
Provider Business Mailing Address Fax Number:
630-447-9942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 E SAINT CHARLES RD STE 204, 205, 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAROL STREAM
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60188-3083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-480-7155
Provider Business Practice Location Address Fax Number:
630-447-9942
Provider Enumeration Date:
07/25/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ZAIMI
Authorized Official First Name:
STELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
630-677-3742

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081N0008X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 68756 . This is a "CORPORATE LICENSE #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".