1609196005 NPI number — ELIZABETH D GODWIN DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609196005 NPI number — ELIZABETH D GODWIN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GODWIN
Provider First Name:
ELIZABETH
Provider Middle Name:
D
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:
BOGENSCHUTZ
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609196005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4334 FOX VALLEY CENTER DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60504-7945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-236-7544
Provider Business Practice Location Address Fax Number:
630-236-7574
Provider Enumeration Date:
06/08/2010

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:  05010407A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 070018999 , 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: 156546 . This is a "GROUP MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100257920 . This is a "GROUP MEDICAID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201004360A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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