1164645008 NPI number — ELM STREET MEDICAL CENTER LTD

Table of content: (NPI 1164645008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164645008 NPI number — ELM STREET MEDICAL CENTER LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELM STREET MEDICAL CENTER LTD
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:
1164645008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4921 W ELM ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MCHENRY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60050-4020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-344-1025
Provider Business Mailing Address Fax Number:
815-344-1208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4921 W ELM ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MCHENRY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60050-4020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-344-1025
Provider Business Practice Location Address Fax Number:
815-344-1208
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REISER
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-344-1025

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038-005010 , 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: 038005010 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05632034 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com