1770746299 NPI number — DR. EMILY MARIE POTT O.D.

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 1770746299 NPI number — DR. EMILY MARIE POTT O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTT
Provider First Name:
EMILY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SOUTHCOTT
Provider Other First Name:
EMILY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770746299
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4160 IL ROUTE 83
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
LONG GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60047-8034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-955-9393
Provider Business Mailing Address Fax Number:
847-955-9857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4160 IL ROUTE 83
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
LONG GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60047-8034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-955-9393
Provider Business Practice Location Address Fax Number:
847-955-9857
Provider Enumeration Date:
07/03/2008

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: 152W00000X , with the licence number:  046010080 , 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: 8825444 . This is a "MULTIPLAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1636706 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 7235044 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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