1205054533 NPI number — NORTHERN ILLINOIS NEPHROLOGY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205054533 NPI number — NORTHERN ILLINOIS NEPHROLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN ILLINOIS NEPHROLOGY
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:
1205054533
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1340 CHARLES ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61104-2200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-398-9590
Provider Business Mailing Address Fax Number:
815-398-9591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1340 CHARLES ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61104-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-398-9590
Provider Business Practice Location Address Fax Number:
815-398-9591
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
815-398-9590

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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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