1386764942 NPI number — DAVID R CULVER OD LTD

Table of content: (NPI 1386764942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386764942 NPI number — DAVID R CULVER OD LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID R CULVER OD LTD
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:
1386764942
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 S RANDOLPH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACOMB
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61455-2210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-833-4391
Provider Business Mailing Address Fax Number:
309-833-1691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 S RANDOLPH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACOMB
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61455-2210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-833-4391
Provider Business Practice Location Address Fax Number:
309-833-1691
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CULVER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
309-833-4391

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  46006825 , 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: 410021980 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5584003 . This is a "BCBS OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL6825 . This is a "EYEMED" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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