1275663338 NPI number — ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL ILLINOIS

Table of content: (NPI 1275663338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275663338 NPI number — ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL ILLINOIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORAL & MAXILLOFACIAL SURGEONS OF CENTRAL ILLINOIS
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:
6
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:
1275663338
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:
5009 A EXECUTIVE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-4866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-693-1200
Provider Business Mailing Address Fax Number:
309-693-9998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5009 A EXECUTIVE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-4866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-693-1200
Provider Business Practice Location Address Fax Number:
309-693-9998
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
ORAL AND MAXILLOFACIAL SURGEON
Authorized Official Telephone Number:
309-693-1200

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223S0112X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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