1609943091 NPI number — DR. VIRGIL A BEADLE DDX

Table of content: DR. VIRGIL A BEADLE DDX (NPI 1609943091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609943091 NPI number — DR. VIRGIL A BEADLE DDX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEADLE
Provider First Name:
VIRGIL
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDX
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:
1609943091
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:
#4 CROWN LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62903-7604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-457-4137
Provider Business Mailing Address Fax Number:
618-351-1081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
#4 CROWN LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62903-7604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-457-4137
Provider Business Practice Location Address Fax Number:
618-351-1081
Provider Enumeration Date:
11/29/2006

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: 122300000X , with the licence number:  19A12875 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 010711 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 010711 . This is a "STATE OF MISSOURI" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 19A12875 . This is a "STATE OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".