1700905205 NPI number — CENTEGRA PRIMARY CARE, LLC

Table of content: (NPI 1700905205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700905205 NPI number — CENTEGRA PRIMARY CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTEGRA PRIMARY CARE, 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:
1700905205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13707 W JACKSON ST
Provider Second Line Business Mailing Address:
CENTEGRA PRIMARY CARE, LLC
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60098-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-206-1060
Provider Business Mailing Address Fax Number:
815-338-6297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13707 W JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60098-3188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-337-2890
Provider Business Practice Location Address Fax Number:
815-338-6297
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TOMLINSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CIO & CFO
Authorized Official Telephone Number:
815-788-5831

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CC7412 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 209584 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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