1659555464 NPI number — KEVIN C DODSON

Table of content: (NPI 1659555464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659555464 NPI number — KEVIN C DODSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEVIN C DODSON
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:
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:
1659555464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 9TH ST
Provider Second Line Business Mailing Address:
P O BOX 664
Provider Business Mailing Address City Name:
EAST MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61244-2120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-755-3809
Provider Business Mailing Address Fax Number:
308-755-3860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61244-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-755-3809
Provider Business Practice Location Address Fax Number:
308-755-3860
Provider Enumeration Date:
12/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DODSON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
309-755-3809

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  016004304 , 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: 0060201286 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL0101 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0436154 . This is a "IME" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: P00204462 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 480007485 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IA0102 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 020110 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 326507258 . This is a "TRICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 36473 . This is a "WELLMARK BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: I12453 . This is a "MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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