1629514989 NPI number — PREMIER SPECIALTY INFUSION LLC

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 1629514989 NPI number — PREMIER SPECIALTY INFUSION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER SPECIALTY INFUSION LLC
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:
1629514989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 HASSEL RD.
Provider Second Line Business Mailing Address:
SUITE 1525
Provider Business Mailing Address City Name:
HOFFMAN ESTATES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60169-7220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-783-9655
Provider Business Mailing Address Fax Number:
877-770-4179

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 HASSELL RD STE 1525
Provider Second Line Business Practice Location Address:
SUITE #1525
Provider Business Practice Location Address City Name:
HOFFMAN ESTATES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60169-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-629-4446
Provider Business Practice Location Address Fax Number:
877-599-0139
Provider Enumeration Date:
01/10/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LARIVIERE
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
866-776-6782

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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