1619914264 NPI number — SHARILYNN R DEBOER PT

Table of content: SHARILYNN R DEBOER PT (NPI 1619914264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619914264 NPI number — SHARILYNN R DEBOER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEBOER
Provider First Name:
SHARILYNN
Provider Middle Name:
R
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:
1619914264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
680 N LAKE SHORE DR
Provider Second Line Business Mailing Address:
SUITE 830
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60611-4546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-943-7850
Provider Business Mailing Address Fax Number:
312-943-0057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6625 W LINCOLN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307-9678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-440-5360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2006

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:  070015010 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 05013218A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 367885100 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 568150 . This is a "MEDICARE GROUP NUMBER" 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".
  • Identifier: 1623066 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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