1063960870 NPI number — MID AMERICA EMERGENCY MEDICINE

Table of content: (NPI 1063960870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063960870 NPI number — MID AMERICA EMERGENCY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID AMERICA EMERGENCY MEDICINE
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:
1063960870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 N PARK AVE APT A
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:
62702-6401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-530-1950
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 N FIRST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62781-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-788-3156
Provider Business Practice Location Address Fax Number:
217-788-6459
Provider Enumeration Date:
09/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ATWOOD
Authorized Official First Name:
ELLEN
Authorized Official Middle Name:
O'BRIEN
Authorized Official Title or Position:
PHYSICIAN ASSISTANT
Authorized Official Telephone Number:
618-530-1950

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  085005966 , 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)





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