1508926684 NPI number — DAVID J FLETCHER MD LLC

Table of content: (NPI 1508926684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508926684 NPI number — DAVID J FLETCHER MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID J FLETCHER MD LLC
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:
SAFE WORKS ILLINOIS
Provider Other Organization Name Type Code:
3
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:
1508926684
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:
1806 N MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-356-6150
Provider Business Mailing Address Fax Number:
217-356-7167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1806 N MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-356-6150
Provider Business Practice Location Address Fax Number:
217-356-7167
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLETCHER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER MEDICAL DIRECTOR
Authorized Official Telephone Number:
217-356-6150

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2083X0100X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 213008 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: K25107 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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