1629152574 NPI number — FIVE APPLES INPATIENT SPECIALISTS

Table of content: AMBER CROCKETT RBT, BS (NPI 1861097057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629152574 NPI number — FIVE APPLES INPATIENT SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE APPLES INPATIENT SPECIALISTS
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:
6
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:
1629152574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
475 BROWN BLVD
Provider Second Line Business Mailing Address:
STE 103
Provider Business Mailing Address City Name:
BOURBONNAIS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-937-7962
Provider Business Mailing Address Fax Number:
815-936-8650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 BROWN BLVD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
BOURBONNAIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-937-7962
Provider Business Practice Location Address Fax Number:
815-936-8650
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
APPLEWHITE
Authorized Official First Name:
TERRILL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-937-7962

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036104924 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0136104924 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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