1588613780 NPI number — DR. SHANE MYLES YORK DPM

Table of content: DR. SHANE MYLES YORK DPM (NPI 1588613780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588613780 NPI number — DR. SHANE MYLES YORK DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YORK
Provider First Name:
SHANE
Provider Middle Name:
MYLES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1588613780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2111 MIDLANDS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYCAMORE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60178-3125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-758-0000
Provider Business Mailing Address Fax Number:
815-756-7130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2111 MIDLANDS CT
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:
60178-3125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-758-0000
Provider Business Practice Location Address Fax Number:
815-756-7130
Provider Enumeration Date:
05/08/2006

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: 213ES0103X , with the licence number:  P-189 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 016-005300 , 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: 119909 . This is a "HEALTH ALLIANCE IDENTIFIE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1915167 . This is a "BLUECROSSBLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 016005300 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03595800001 . This is a "DMERC IDENTIFIER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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