1366599854 NPI number — STEPHEN & FRED SHRADER PTR

Table of content: (NPI 1366599854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366599854 NPI number — STEPHEN & FRED SHRADER PTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN & FRED SHRADER PTR
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:
1366599854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 277
Provider Second Line Business Mailing Address:
204 N. LOCUST ST
Provider Business Mailing Address City Name:
ARCOLA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61910-0277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-268-4848
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 N LOCUST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCOLA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61910-1407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-268-4848
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHRADER
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
217-268-4848

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  670002 , 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: 2190002 . This is a "BCBS NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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