1679745293 NPI number — RUSH-COPLEY MEDICAL GROUP

Table of content: (NPI 1679745293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679745293 NPI number — RUSH-COPLEY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSH-COPLEY MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1679745293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1256 WATERFORD DR STE 230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60504-4511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-499-2404
Provider Business Mailing Address Fax Number:
630-692-5518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2040 OGDEN AVE
Provider Second Line Business Practice Location Address:
STE 30
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60504-7222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-978-6770
Provider Business Practice Location Address Fax Number:
630-978-6773
Provider Enumeration Date:
03/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRUMMEL
Authorized Official First Name:
MARCEE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
630-978-4915

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  036-110500 , 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: 208039 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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