1225122419 NPI number — THE LIBERTYVILLE SURGEONS, S C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225122419 NPI number — THE LIBERTYVILLE SURGEONS, S C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE LIBERTYVILLE SURGEONS, S C
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:
1225122419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
890 GARFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-4723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-367-1800
Provider Business Mailing Address Fax Number:
847-367-1825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 GARFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-4723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-367-1800
Provider Business Practice Location Address Fax Number:
847-367-1825
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HABEL
Authorized Official First Name:
EILEEN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
847-367-1800

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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: 1447265871 . This is a "NPI WILLIAM WATSON MD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com