1467494310 NPI number — MR. JEFFREY W FLEISCHLI DPM

Table of content: MR. JEFFREY W FLEISCHLI DPM (NPI 1467494310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467494310 NPI number — MR. JEFFREY W FLEISCHLI DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLEISCHLI
Provider First Name:
JEFFREY
Provider Middle Name:
W
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1467494310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1745 W WALNUT ST STE 12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62650-6126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-532-6279
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1745 W WALNUT ST STE 12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62650-6126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-532-6279
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2006

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: 213ES0103X , with the licence number:  016005038 , 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: 016005038/4974780001 . This is a "MEDICARE DMERC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 533079/270056166 . This is a "HEALTHLINK PPO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: RAILROAD MEDICARE . This is a "P00027608/DA1788" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 06932011 . This is a "BCBS OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 016005038 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: HEALTH ALLIANCE . This is a "072022" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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