1336361922 NPI number — AMSOL ANESTHETISTS OF LITCHFIELD IL

Table of content: BRADLEY RANDALL CONGLETON DMD (NPI 1952754749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336361922 NPI number — AMSOL ANESTHETISTS OF LITCHFIELD IL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMSOL ANESTHETISTS OF LITCHFIELD IL
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:
1336361922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 610201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75261-0201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-394-4445
Provider Business Mailing Address Fax Number:
205-322-1851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1215 FRANCISCAN DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITCHFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62056-1778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-324-2191
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EICHENHOLZ
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-687-0001

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06832024 . This is a "BLUE CROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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