1821380064 NPI number — OSF CHILDREN'S MEDICAL GROUP - CONGENITAL HEART CENTER, LLC

Table of content: (NPI 1821380064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821380064 NPI number — OSF CHILDREN'S MEDICAL GROUP - CONGENITAL HEART CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OSF CHILDREN'S MEDICAL GROUP - CONGENITAL HEART CENTER, LLC
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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1821380064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 NE GLEN OAK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61603-3255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-655-2880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5701 STRATHMOOR DR
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61107-5182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-227-5600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SCHOEPLEIN
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
309-655-2880

Provider Taxonomy Codes

  • Taxonomy code: 2080P0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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