1386736338 NPI number — DAVID G PRESKILL MD

Table of content: DAVID G PRESKILL MD (NPI 1386736338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386736338 NPI number — DAVID G PRESKILL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRESKILL
Provider First Name:
DAVID
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1386736338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 W ROCKLAND RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-2774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-362-0100
Provider Business Mailing Address Fax Number:
847-918-0426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 S MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
110
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-362-0100
Provider Business Practice Location Address Fax Number:
847-918-0426
Provider Enumeration Date:
09/28/2006

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: 207V00000X , with the licence number:  036081833 , 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: 04923779 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0364390885 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".




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