1104892215 NPI number — DR. EILEEN CASTRO MD

Table of content: DR. EILEEN CASTRO MD (NPI 1104892215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104892215 NPI number — DR. EILEEN CASTRO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTRO
Provider First Name:
EILEEN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1104892215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 19TH AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61265-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-779-7050
Provider Business Mailing Address Fax Number:
309-779-7055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 19TH AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-779-7050
Provider Business Practice Location Address Fax Number:
309-779-7055
Provider Enumeration Date:
02/28/2006

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: 207R00000X , with the licence number:  036104609 , 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: 1571000 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036104609 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0571000 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1104892215 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036104609 . This is a "BC ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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