1699738997 NPI number — TAMI J DEMAY LPT

Table of content: TAMI J DEMAY LPT (NPI 1699738997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699738997 NPI number — TAMI J DEMAY LPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMAY
Provider First Name:
TAMI
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPT
Provider Gender Code:
F

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:
1699738997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 E COLLEGE AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61761-4623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-663-6777
Provider Business Practice Location Address Fax Number:
309-663-6779
Provider Enumeration Date:
04/08/2006

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: 174400000X , with the licence number:  PT002755E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 070018837 , 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: 819711 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20-2108080 . This is a "TRICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 267233 . This is a "HEALTH AMERICA PROV #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1062692 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00256578 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1014316410001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001766902 . This is a "BC/ BS/ NE PA IND PROV #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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