1437268604 NPI number — SPOON RIVER FAMILY PRACTICE CENTER, INC

Table of content: (NPI 1437268604)

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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