1649414558 NPI number — MRS. BERNADETTE KATHLENE SOBCZAK C.P.N.P. PRIMARY CAR

Table of content: MRS. BERNADETTE KATHLENE SOBCZAK C.P.N.P. PRIMARY CAR (NPI 1649414558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649414558 NPI number — MRS. BERNADETTE KATHLENE SOBCZAK C.P.N.P. PRIMARY CAR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOBCZAK
Provider First Name:
BERNADETTE
Provider Middle Name:
KATHLENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
C.P.N.P. PRIMARY CAR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORDIS
Provider Other First Name:
BERNADETTE
Provider Other Middle Name:
KATHLENE
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:
1649414558
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
807 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILLESPIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-839-3900
Provider Business Mailing Address Fax Number:
217-839-1313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
807 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILLESPIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-839-3900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2009

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: 363LP0200X , with the licence number:  209-007531 , 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)





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