1588653935 NPI number — RENEE ALWAN PERCELL P.A.-C.

Table of content: RENEE ALWAN PERCELL P.A.-C. (NPI 1588653935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588653935 NPI number — RENEE ALWAN PERCELL P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALWAN PERCELL
Provider First Name:
RENEE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALWAN
Provider Other First Name:
RENEE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588653935
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 E COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61704-2101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-664-3000
Provider Business Mailing Address Fax Number:
309-664-3026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 E COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61704-2101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-664-3000
Provider Business Practice Location Address Fax Number:
309-664-3026
Provider Enumeration Date:
10/18/2005

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: 363A00000X , with the licence number:  3289 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: IL2613 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 031815 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 031820 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 3289 . This is a "LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 031813 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 031814 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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