1407945827 NPI number — DR. MELODY JOY DERRICK M.D.

Table of content: DR. MELODY JOY DERRICK M.D. (NPI 1407945827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407945827 NPI number — DR. MELODY JOY DERRICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERRICK
Provider First Name:
MELODY
Provider Middle Name:
JOY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DERRICK
Provider Other First Name:
MELODY
Provider Other Middle Name:
JOY
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407945827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 N WINFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60190-1295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-260-0600
Provider Business Mailing Address Fax Number:
630-260-1370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 N WINFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60190-1295
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-260-0600
Provider Business Practice Location Address Fax Number:
630-260-1370
Provider Enumeration Date:
10/12/2006

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: 207Q00000X , with the licence number:  036-114979 , 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: P00386296 . This is a "RR MEDICARE (INDIVIDUAL)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036114979 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".