1285657379 NPI number — SIU PHYSICIANS & SURGEONS, INC

Table of content: (NPI 1285657379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285657379 NPI number — SIU PHYSICIANS & SURGEONS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIU PHYSICIANS & SURGEONS, 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:
1285657379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19639
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62794-9639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-545-7578
Provider Business Mailing Address Fax Number:
217-545-1884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 N 1ST ST
Provider Second Line Business Practice Location Address:
D235
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62781-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-545-7578
Provider Business Practice Location Address Fax Number:
217-545-1884
Provider Enumeration Date:
07/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TKACH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
217-545-7578

Provider Taxonomy Codes

  • Taxonomy code: 207SG0201X , with the licence number:  ========= , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0006X , with the licence number: ========= , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0206X , with the licence number: ========= , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0208X , with the licence number: ========= , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0210X , with the licence number: ========= , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: ========= , 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: CB2589 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE8931 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE8689 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE8686 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE8687 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CE8688 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".