1326064296 NPI number — JANICE TAKATA ROSSI MD SC

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 1326064296 NPI number — JANICE TAKATA ROSSI MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JANICE TAKATA ROSSI MD 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:
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:
1326064296
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 SO FOURTH
Provider Second Line Business Mailing Address:
STE 140
Provider Business Mailing Address City Name:
MORTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-263-6154
Provider Business Mailing Address Fax Number:
309-263-6111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 SO FOURTH
Provider Second Line Business Practice Location Address:
STE 140
Provider Business Practice Location Address City Name:
MORTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-263-6154
Provider Business Practice Location Address Fax Number:
309-263-6111
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAKATA ROSSI
Authorized Official First Name:
JANICE
Authorized Official Middle Name:
LOURENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-263-6154

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036-065144 , 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: 036065144 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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