1891744215 NPI number — MID-CENTRAL MEDICAL INC

Table of content: (NPI 1891744215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891744215 NPI number — MID-CENTRAL MEDICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-CENTRAL MEDICAL INC
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:
6
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:
1891744215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
281 E JACKSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRDEN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62690-1451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-965-3734
Provider Business Mailing Address Fax Number:
217-965-3371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
281 E JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIRDEN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62690-1451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-965-3734
Provider Business Practice Location Address Fax Number:
217-965-3371
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BURTLE
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
217-965-3734

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  203.000130 , 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: 1696366 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90212333 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 626170807 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200334860A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4581903 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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