1902852940 NPI number — ANDREA IKEDA M.S., C.P., L.P.

Table of content: ANDREA IKEDA M.S., C.P., L.P. (NPI 1902852940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902852940 NPI number — ANDREA IKEDA M.S., C.P., L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IKEDA
Provider First Name:
ANDREA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., C.P., L.P.
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:
1902852940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 N LARKIN AVE
Provider Second Line Business Mailing Address:
STE. 207
Provider Business Mailing Address City Name:
JOLIET
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60435-3438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-207-4200
Provider Business Mailing Address Fax Number:
815-207-4100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 N LARKIN AVE
Provider Second Line Business Practice Location Address:
STE. 207
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435-3438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-207-4200
Provider Business Practice Location Address Fax Number:
815-207-4100
Provider Enumeration Date:
05/25/2006

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: 224P00000X , 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: 09932112 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 113671669001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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