1487927265 NPI number — TERRY I MERIDEN MD SC

Table of content: (NPI 1487927265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487927265 NPI number — TERRY I MERIDEN MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRY I MERIDEN MD SC
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:
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:
1487927265
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61602-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-673-1717
Provider Business Mailing Address Fax Number:
309-673-7221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61602-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-673-1717
Provider Business Practice Location Address Fax Number:
309-673-7221
Provider Enumeration Date:
02/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MERIDEN
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
309-673-1717

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  0360586021 , 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: 036058602 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 792111124 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 9000138 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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