1649462672 NPI number — BRIAN J ANSEEUW M.D. S.C.

Table of content: (NPI 1649462672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649462672 NPI number — BRIAN J ANSEEUW M.D. S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN J ANSEEUW M.D. S.C.
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:
1649462672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
616 35TH AVE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61265-6158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-764-4729
Provider Business Mailing Address Fax Number:
309-764-7144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
616 35TH AVE
Provider Second Line Business Practice Location Address:
UNIT 2
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-764-4729
Provider Business Practice Location Address Fax Number:
309-764-7144
Provider Enumeration Date:
08/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANSEEUW
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
309-764-4729

Provider Taxonomy Codes

  • Taxonomy code: 204D00000X , with the licence number:  042618374 , 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: 036102718 2 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 94420 . This is a "WELLMARK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 08126230 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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