1942300033 NPI number — AMY ELIZABETH UNDERWOOD PA-C

Table of content: AMY ELIZABETH UNDERWOOD PA-C (NPI 1942300033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942300033 NPI number — AMY ELIZABETH UNDERWOOD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UNDERWOOD
Provider First Name:
AMY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1942300033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4201 W MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCHENRY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60050-8409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-759-3100
Provider Business Mailing Address Fax Number:
815-363-9044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 W MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCHENRY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60050-8409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-759-3100
Provider Business Practice Location Address Fax Number:
815-363-9044
Provider Enumeration Date:
09/25/2006

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: 363A00000X , with the licence number:  085-004651 , 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: 86G34UN . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP37197 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1030499 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1600377 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6609328 . This is a "MEDICA URGENT CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 414378700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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