1700332392 NPI number — NORTHERN ILLINOIS UNIVERSITY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700332392 NPI number — NORTHERN ILLINOIS UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN ILLINOIS UNIVERSITY
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:
NORTHERN ILLINOIS UNIVERSITY SPORTS MEDICINE
Provider Other Organization Name Type Code:
3
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:
1700332392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 SPRING VALLEY RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75244-3909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 W LINCOLN HWY
Provider Second Line Business Practice Location Address:
CONVOCATION CENTER
Provider Business Practice Location Address City Name:
DEKALB
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60115-2828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-753-7225
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BASS
Authorized Official First Name:
MOUZON
Authorized Official Middle Name:
Authorized Official Title or Position:
AGENT
Authorized Official Telephone Number:
972-367-4845

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  036.08668 , 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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