1427345131 NPI number — SELECT PSYCHIATRIC MANAGEMENT GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427345131 NPI number — SELECT PSYCHIATRIC MANAGEMENT GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SELECT PSYCHIATRIC MANAGEMENT GROUP LLC
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:
1427345131
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 AIRWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62959-5841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-998-0888
Provider Business Mailing Address Fax Number:
618-993-1808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 DR WARREN TUTTLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62946-2718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-252-0999
Provider Business Practice Location Address Fax Number:
618-252-2032
Provider Enumeration Date:
07/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
QURESHI
Authorized Official First Name:
NAEEM
Authorized Official Middle Name:
AKHTAR
Authorized Official Title or Position:
MEMBER MANAGER
Authorized Official Telephone Number:
618-998-0888

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , 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: 036094666 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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