1952697492 NPI number — SPRINGFIELD CLINIC MT PULASKI LAB

Table of content: (NPI 1952697492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952697492 NPI number — SPRINGFIELD CLINIC MT PULASKI LAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGFIELD CLINIC MT PULASKI LAB
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:
1952697492
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 S 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62703-2403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-528-7541
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1112 N TOPPER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT PULASKI
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62548-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-792-3756
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NERONE
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VICE PRESIDENT & CFO
Authorized Official Telephone Number:
217-528-7541

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14D2025259 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".




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