1386873248 NPI number — JORI L SHEA MPT

Table of content: JORI L SHEA MPT (NPI 1386873248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386873248 NPI number — JORI L SHEA MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEA
Provider First Name:
JORI
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SEYMOUR
Provider Other First Name:
JORI
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386873248
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 N ARLINGTON HEIGHTS RD
Provider Second Line Business Mailing Address:
SUITE 170
Provider Business Mailing Address City Name:
BUFFALO GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60089-1783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-676-0450
Provider Business Mailing Address Fax Number:
224-676-0448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 N ARLINGTON HEIGHTS RD
Provider Second Line Business Practice Location Address:
SUITE 170
Provider Business Practice Location Address City Name:
BUFFALO GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60089-1783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-676-0450
Provider Business Practice Location Address Fax Number:
224-676-0448
Provider Enumeration Date:
07/13/2009

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: 225100000X , with the licence number:  070010526 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 11584-24 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: IL6237004 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL6238004 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 859400060 . This is a "MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: IL6697007 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1386873248 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 539320003 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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