1568444008 NPI number — MS. EVELEEN M ACKERMAN F.N.P.

Table of content: MS. EVELEEN M ACKERMAN F.N.P. (NPI 1568444008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568444008 NPI number — MS. EVELEEN M ACKERMAN F.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ACKERMAN
Provider First Name:
EVELEEN
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
F.N.P.
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:
1568444008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 PARKVIEW AVE
Provider Second Line Business Mailing Address:
CREDENTIALING S200
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61107-1822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-395-5861
Provider Business Mailing Address Fax Number:
815-395-5575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 E STATE ST
Provider Second Line Business Practice Location Address:
UNIVERSITY FAMILY HEALTH CENTER
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61104-2231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-972-1000
Provider Business Practice Location Address Fax Number:
815-972-1033
Provider Enumeration Date:
11/18/2005

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: 363LF0000X , with the licence number:  209001986 , 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: 209001986 . This is a "IL STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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