1437268604 NPI number — SPOON RIVER FAMILY PRACTICE CENTER, INC

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 1437268604 NPI number — SPOON RIVER FAMILY PRACTICE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPOON RIVER FAMILY PRACTICE CENTER, INC
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:
1437268604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 E SIDE SQ
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61520-2671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-647-9980
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 E SIDE SQ
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61520-2671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-647-9980
Provider Business Practice Location Address Fax Number:
309-647-7792
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FORESTIER
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-647-9980

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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: IL0101 . This is a "JOHN DEERE PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DA4719 . This is a "MEDICARE RAILROAD GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0002932001 . This is a "BLUE CROSS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 014152 . This is a "HEALTH ALLIANCE PROVDIER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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