1487764718 NPI number — CONSTANCE H VANNI PT

Table of content: CONSTANCE H VANNI PT (NPI 1487764718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487764718 NPI number — CONSTANCE H VANNI PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANNI
Provider First Name:
CONSTANCE
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1487764718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 S EASTWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60098-3519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-334-0400
Provider Business Mailing Address Fax Number:
815-334-0800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 S EASTWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60098-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-334-0400
Provider Business Practice Location Address Fax Number:
815-334-0800
Provider Enumeration Date:
08/30/2006

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: 225100000X , with the licence number:  070004961 , 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: 568150 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 567700 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DC7571 . This is a "R R MEDICARE GRP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00199532 . This is a "R R MEDICARE PIN #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 568080 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1623066 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 367885100 . This is a "US DEPT OF LABOR PROV #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1619908 . This is a "BCBS IL GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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