1417352105 NPI number — PROVIDER HEALTHCARE SERVICES, INC

Table of content: (NPI 1417352105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417352105 NPI number — PROVIDER HEALTHCARE SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDER HEALTHCARE SERVICES, INC
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:
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:
1417352105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 S SCHUYLER AVE
Provider Second Line Business Mailing Address:
SUITE 275
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-5146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-301-8464
Provider Business Mailing Address Fax Number:
773-530-2643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 SOUTH SCHUYLER
Provider Second Line Business Practice Location Address:
SUITE 275
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-301-8464
Provider Business Practice Location Address Fax Number:
773-530-2643
Provider Enumeration Date:
10/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
OLADIPO
Authorized Official First Name:
SULAIMON
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-301-8464

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1011663 , 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)





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