1467978882 NPI number — JAMIESON T CREDILLE DPT

Table of content: JAMIESON T CREDILLE DPT (NPI 1467978882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467978882 NPI number — JAMIESON T CREDILLE DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CREDILLE
Provider First Name:
JAMIESON
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

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:
1467978882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1952 ABERDEEN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYCAMORE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60178-3175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-991-2333
Provider Business Mailing Address Fax Number:
815-748-3014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1513 DEKALB AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYCAMORE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60178-2703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-758-0000
Provider Business Practice Location Address Fax Number:
815-991-9484
Provider Enumeration Date:
08/17/2017

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: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 070023046 . This is a "PHYSICAL THERAPIST LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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