1134185564 NPI number — DECATUR DIGESTIVE DISEASE CENTER LLC

Table of content: (NPI 1134185564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134185564 NPI number — DECATUR DIGESTIVE DISEASE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DECATUR DIGESTIVE DISEASE CENTER LLC
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:
1134185564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 MEMORIAL DR SUITE 102
Provider Second Line Business Mailing Address:
PHYSICIAN PLAZA WEST
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62526-3950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-233-0003
Provider Business Mailing Address Fax Number:
217-233-0077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 MEMORIAL DR SUITE 102
Provider Second Line Business Practice Location Address:
PHYSICIAN PLAZA WEST
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62526-3950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-233-0003
Provider Business Practice Location Address Fax Number:
217-233-0077
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELOY
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
217-233-0003

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  7002983 , 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: 50402 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00257307 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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