1205958741 NPI number — WESTERN ILLINOIS MEDICAL GROUP, LLC

Table of content: (NPI 1205958741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205958741 NPI number — WESTERN ILLINOIS MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN ILLINOIS MEDICAL GROUP, 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:
1205958741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 E GRANT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACOMB
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61455-3371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-837-7546
Provider Business Mailing Address Fax Number:
126-747-5463

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 E GRANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACOMB
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61455-3371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-837-7546
Provider Business Practice Location Address Fax Number:
312-674-7546
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LI
Authorized Official First Name:
XIAOLU
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
309-837-7546

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 036099467 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 039099467 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05532018 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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