1336208842 NPI number — DR. DANIEL L SYVERSON DPM

Table of content: DR. DANIEL L SYVERSON DPM (NPI 1336208842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336208842 NPI number — DR. DANIEL L SYVERSON DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SYVERSON
Provider First Name:
DANIEL
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

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:
1336208842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 311
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSCOE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61073-0311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-389-8088
Provider Business Mailing Address Fax Number:
815-389-3431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11320 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
ROSCOE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61073-4612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-389-8088
Provider Business Practice Location Address Fax Number:
815-389-3431
Provider Enumeration Date:
12/08/2006

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: 213EP1101X , with the licence number:  014004040 , 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: 016004040 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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