1063499622 NPI number — DR. TRACEY LYNN DRENNEN-ALEXANDER D.C.

Table of content: DR. TRACEY LYNN DRENNEN-ALEXANDER D.C. (NPI 1063499622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063499622 NPI number — DR. TRACEY LYNN DRENNEN-ALEXANDER D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRENNEN-ALEXANDER
Provider First Name:
TRACEY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.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:
1063499622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1002 N STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREEBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62243-4008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-539-3333
Provider Business Mailing Address Fax Number:
618-539-2222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREEBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62243-4008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-539-3333
Provider Business Practice Location Address Fax Number:
618-539-2222
Provider Enumeration Date:
12/26/2005

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: 111N00000X , with the licence number:  038-009402 , 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: 473545 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1030171 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 157115 . This is a "BC/BS OF MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 8232017 . This is a "BC/BS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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