1558411470 NPI number — MS. STEPHANIE L DAVIES OTRL

Table of content: MS. STEPHANIE L DAVIES OTRL (NPI 1558411470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558411470 NPI number — MS. STEPHANIE L DAVIES OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIES
Provider First Name:
STEPHANIE
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

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:
1558411470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 W MONTROSE AVE
Provider Second Line Business Mailing Address:
#504
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60613-5520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-477-7599
Provider Business Mailing Address Fax Number:
773-477-7601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1962 N BISSELL ST
Provider Second Line Business Practice Location Address:
2 ND FLOOR
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60614-5015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-477-7599
Provider Business Practice Location Address Fax Number:
773-477-7601
Provider Enumeration Date:
01/11/2007

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: 225X00000X , with the licence number:  056-003210 , 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: 01635519 . This is a "BCBS OF ILLINOIS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com