1689646127 NPI number — DR. JOHN GREGG FOZARD M.D.

Table of content: DR. JOHN GREGG FOZARD M.D. (NPI 1689646127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689646127 NPI number — DR. JOHN GREGG FOZARD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOZARD
Provider First Name:
JOHN
Provider Middle Name:
GREGG
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1689646127
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5383 STATE ROUTE 154
Provider Second Line Business Mailing Address:
PO BOX 437
Provider Business Mailing Address City Name:
PINCKNEYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62274-3342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-357-2131
Provider Business Mailing Address Fax Number:
618-357-3411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5383 STATE ROUTE 154
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINCKNEYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62274-3342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-357-2131
Provider Business Practice Location Address Fax Number:
618-357-3411
Provider Enumeration Date:
02/07/2006

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: 207Q00000X , with the licence number:  036053225 , 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: 7320380 . This is a "BCBS FMC GROUP PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 080174912 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036053225 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2288028 . This is a "UNITED HEALTHCARE ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0027340080 . This is a "BCBS PHYS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 034761 . This is a "HEALTH ALLIANCE ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 122435 . This is a "HEALTHLINK PROVIDER ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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