1912902115 NPI number — DR. BILL M PARK O.D.

Table of content: DR. BILL M PARK O.D. (NPI 1912902115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912902115 NPI number — DR. BILL M PARK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
BILL
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

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:
1912902115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 S LINCOLNWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60542-1608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
638-844-2500
Provider Business Mailing Address Fax Number:
630-844-2599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 S LINCOLNWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60542-1608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
638-844-2500
Provider Business Practice Location Address Fax Number:
630-844-2599
Provider Enumeration Date:
06/15/2005

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:  046 007008 , 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: 363187524 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: K37007 . This is a "MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 4584027 . This is a "BCBS PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 363187524 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5534404 . This is a "CCN PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 363187524 . This is a "PHCS PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2218742 . This is a "FIRST HEALTH PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 11437952 . This is a "CAQH PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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