1215105192 NPI number — DR. GRAHAM ROWELL HUESMANN MD/PHD

Table of content: DR. GRAHAM ROWELL HUESMANN MD/PHD (NPI 1215105192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215105192 NPI number — DR. GRAHAM ROWELL HUESMANN MD/PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUESMANN
Provider First Name:
GRAHAM
Provider Middle Name:
ROWELL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD/PHD
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:
1215105192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 W. PARK ST
Provider Second Line Business Mailing Address:
FAPC
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 W PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
URBANA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61801-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-383-3440
Provider Business Practice Location Address Fax Number:
217-383-3171
Provider Enumeration Date:
02/13/2008

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: 2084N0400X , with the licence number:  237522 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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