1346243979 NPI number — CENTRAD HEALTHCARE LLC

Table of content: (NPI 1346243979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346243979 NPI number — CENTRAD HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAD HEALTHCARE LLC
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:
1346243979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
184 SHUMAN BLVD
Provider Second Line Business Mailing Address:
STE 130
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60563-8474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-369-5840
Provider Business Mailing Address Fax Number:
630-369-5436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
184 SHUMAN BLVD
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60563-8474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-369-5840
Provider Business Practice Location Address Fax Number:
630-369-5436
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KORSLIN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT, CEO
Authorized Official Telephone Number:
630-369-5840

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  203-000502 , 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: 18130372 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0530980 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 221343500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8705402 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: MS284IL , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75 871044 01 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02163179 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200287520A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 520115 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8251002 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003107879 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00876191A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02230052 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 52482 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00440846 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009974810 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1431532 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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