1487678652 NPI number — DR. JEFFREY A MCFADDEN DO

Table of content: DR. JEFFREY A MCFADDEN DO (NPI 1487678652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487678652 NPI number — DR. JEFFREY A MCFADDEN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCFADDEN
Provider First Name:
JEFFREY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1487678652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
602 W UNIVERSITY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61801-2530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-383-6792
Provider Business Mailing Address Fax Number:
217-326-2856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 GATEWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYCAMORE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60178-3192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-758-8671
Provider Business Practice Location Address Fax Number:
815-758-5605
Provider Enumeration Date:
07/27/2006

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:  02002556A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036104766 , 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: 147HR . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 02002556A . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 812085 . This is a "PARTNERS/BLUE MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 02002556B . This is a "STATE CONTROLLED LIC" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 5907839 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036104766 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 336090764 . This is a "STATE CONTROLLED LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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