1255399614 NPI number — ILLINOIS MEDI-CAR, INC

Table of content: (NPI 1255399614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255399614 NPI number — ILLINOIS MEDI-CAR, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS MEDI-CAR, INC
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:
1255399614
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
395 W LAKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-832-2012
Provider Business Mailing Address Fax Number:
630-832-2169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
395 W LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMHURST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-832-2012
Provider Business Practice Location Address Fax Number:
630-832-2169
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HILL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-832-2012

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , 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: 000000273016 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 362812586001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100030530B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 022-70589 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200319500A . This is a "LCP TRANSPORTATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 80446300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200319500A . This is a "HOOSIER HEALTH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 703025410 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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