1952579054 NPI number — EDEN AURELIO MD SC

Table of content: (NPI 1952579054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952579054 NPI number — EDEN AURELIO MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDEN AURELIO MD SC
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952579054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 17TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61244-2028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-755-4548
Provider Business Mailing Address Fax Number:
309-755-4774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 17TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61244-2028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-755-4548
Provider Business Practice Location Address Fax Number:
309-755-4774
Provider Enumeration Date:
02/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
AURELIO
Authorized Official First Name:
EDEN
Authorized Official Middle Name:
GONZALES
Authorized Official Title or Position:
MD PHYSICIAN
Authorized Official Telephone Number:
309-755-4548

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 36066418 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08105516 . This is a "BCBS OF IL" identifier . This identifiers is of the category "OTHER".




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