1538165667 NPI number — OPTIMA MEDICAL ASSOCIATES, LTD

Table of content: (NPI 1538165667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538165667 NPI number — OPTIMA MEDICAL ASSOCIATES, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMA MEDICAL ASSOCIATES, LTD
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:
SOUTHWEST CENTER FOR MEDICAL EXCELLENCE
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:
1538165667
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:
1050 ESSINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOLIET
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60435-8415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-729-0129
Provider Business Mailing Address Fax Number:
815-729-1643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 ESSINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435-8415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-729-0129
Provider Business Practice Location Address Fax Number:
815-729-1643
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NEWTON
Authorized Official First Name:
JANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE ADMINSTRATOR
Authorized Official Telephone Number:
815-729-0129

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RG0300X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RP1001X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LF0000X , 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: 09919564 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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