1326006396 NPI number — DR. MICHAEL W SAMPLE DC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326006396 NPI number — DR. MICHAEL W SAMPLE DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMPLE
Provider First Name:
MICHAEL
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAMPLE
Provider Other First Name:
DAWN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1326006396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANTENO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60950-1534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-468-7787
Provider Business Mailing Address Fax Number:
815-468-0154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANTENO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60950-1534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-468-7787
Provider Business Practice Location Address Fax Number:
815-468-0154
Provider Enumeration Date:
05/01/2006

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: 111N00000X , 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: 4619978 . This is a "BC/BS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com