1659489250 NPI number — WILLIAM R BUCKLEY MD

Table of content: WILLIAM R BUCKLEY MD (NPI 1659489250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659489250 NPI number — WILLIAM R BUCKLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLEY
Provider First Name:
WILLIAM
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1659489250
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61520-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-647-0201
Provider Business Mailing Address Fax Number:
309-649-5302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61520-2608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-647-0201
Provider Business Practice Location Address Fax Number:
309-647-9652
Provider Enumeration Date:
08/25/2006

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: 208600000X , with the licence number:  0360851714 , 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: 085171 . This is a "OSF HEALTHPLANS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 222121 . This is a "HEALTH LINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CG5172 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02922981 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0062839 . This is a "UMWA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200397 . This is a "BLACK LUNG" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 014155 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036085171 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1942315197 . This is a "NPI CLINIC NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL0116 . This is a "JOHN DEERE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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