1487747556 NPI number — INNOVATIVE OUTPATIENT MEDICAL SYSTEMS

Table of content: (NPI 1487747556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487747556 NPI number — INNOVATIVE OUTPATIENT MEDICAL SYSTEMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE OUTPATIENT MEDICAL SYSTEMS
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:
1487747556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18425 WEST CREEK DRIVE
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
TINLEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60477-6767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-532-1337
Provider Business Mailing Address Fax Number:
708-532-1899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18425 WEST CREEK DRIVE
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
TINLEY PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60477-6767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-532-1337
Provider Business Practice Location Address Fax Number:
708-532-1899
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEJONG
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
708-532-1337

Provider Taxonomy Codes

  • Taxonomy code: 261QR0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9932192 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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