1699728584 NPI number — MUKTESHWAR MEHRA MD

Table of content: MUKTESHWAR MEHRA MD (NPI 1699728584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699728584 NPI number — MUKTESHWAR MEHRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEHRA
Provider First Name:
MUKTESHWAR
Provider Middle Name:
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:
MEHRA
Provider Other First Name:
M
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1699728584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATHAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62629-0500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-698-9722
Provider Business Mailing Address Fax Number:
217-391-0392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 OLD JACKSONVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62704-7437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-698-9722
Provider Business Practice Location Address Fax Number:
217-391-0392
Provider Enumeration Date:
05/19/2006

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: 2084N0400X , with the licence number:  036046419 , 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: 330617 . This is a "PERSONAL CARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CD7143 . This is a "PGA RR MEDICARE GROUP#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036046419 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08421024 . This is a "BC/BS PGA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 262941 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 6394P . This is a "CATERPILLAR PGA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00453807 . This is a "RR MED ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 020057300 . This is a "BLACK LUNG PGA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 14D0949277 . This is a "CLIA PGA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036046419 . This is a "IL STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 133586700 . This is a "ACS-OWCP PGA GROUP#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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