1063538312 NPI number — MED-PEDS ASSOCIATES,P.C.

Table of content: (NPI 1063538312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063538312 NPI number — MED-PEDS ASSOCIATES,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED-PEDS ASSOCIATES,P.C.
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:
1063538312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 N WALL ST
Provider Second Line Business Mailing Address:
STE P520
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-3483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-933-0194
Provider Business Mailing Address Fax Number:
815-933-1444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 N WALL ST
Provider Second Line Business Practice Location Address:
STE P520
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901-3483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-933-0194
Provider Business Practice Location Address Fax Number:
815-933-1444
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCUISTON
Authorized Official First Name:
STONEWALL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
815-933-0194

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036074737 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 036074737 , 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: 036074737 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4623239 . This is a "BLUE CROSS/BLUE SHIELD OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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