1023369212 NPI number — MRS. ABIGAIL BOETHIN P.A.-C

Table of content: MRS. ABIGAIL BOETHIN P.A.-C (NPI 1023369212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023369212 NPI number — MRS. ABIGAIL BOETHIN P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOETHIN
Provider First Name:
ABIGAIL
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-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:
1023369212
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 W PARK ST
Provider Second Line Business Mailing Address:
FAPC
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 W PARK ST
Provider Second Line Business Practice Location Address:
FAPC
Provider Business Practice Location Address City Name:
URBANA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-904-7000
Provider Business Practice Location Address Fax Number:
217-904-7748
Provider Enumeration Date:
09/27/2012

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:  2012033522 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 2012033522 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 2012033522 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 085007968 , 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)





Copyright © 2007-2025 www.npivalidator.com