1275673295 NPI number — RENEE MICHELLE SPANBURG PT

Table of content: RENEE MICHELLE SPANBURG PT (NPI 1275673295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275673295 NPI number — RENEE MICHELLE SPANBURG PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPANBURG
Provider First Name:
RENEE MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1275673295
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 W WACKER DR
Provider Second Line Business Mailing Address:
SUITE 1020
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60606-1216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-640-0329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 N CONVENT ST
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
BOURBONNAIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60914-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-928-8357
Provider Business Practice Location Address Fax Number:
815-929-0492
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  070011168 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 568080 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 145210E . This is a "MEDICARE GROUP NUMBER-IN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1619908 . This is a "BCBS IL GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 568150 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 567700 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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