1992814628 NPI number — JEROME S WEISKOPF MD

Table of content: JEROME S WEISKOPF MD (NPI 1992814628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992814628 NPI number — JEROME S WEISKOPF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEISKOPF
Provider First Name:
JEROME
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1992814628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6533 LEXUS DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61108-3015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-397-4180
Provider Business Mailing Address Fax Number:
815-397-1250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6533 LEXUS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61108-3015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-397-4180
Provider Business Practice Location Address Fax Number:
815-397-1250
Provider Enumeration Date:
08/29/2006

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: 2086S0105X , with the licence number:  03652893 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0122X , with the licence number: 03652893 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 362958896015 . This is a "BLUE CROSS OF WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 131087000 . This is a "US DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 101-00485 . This is a "BLUE CROSS IF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036052893 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 31303800 . This is a "WI PUBLIC AID" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 791240158 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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