1710996103 NPI number — DR. ABIGAIL ALAYNE MAHONEY DPM

Table of content: DR. ABIGAIL ALAYNE MAHONEY DPM (NPI 1710996103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710996103 NPI number — DR. ABIGAIL ALAYNE MAHONEY DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHONEY
Provider First Name:
ABIGAIL
Provider Middle Name:
ALAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

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:
1710996103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 N KNOXVILLE AVE
Provider Second Line Business Mailing Address:
STE 117
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-5068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-689-8888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5017 N GLEN PARK PLACE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-4677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-691-1589
Provider Business Practice Location Address Fax Number:
309-692-2032
Provider Enumeration Date:
08/05/2006

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: 213ES0103X , with the licence number:  016005175 , 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: 016005175 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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