1730151572 NPI number — DENNIS M BRTVA

Table of content: (NPI 1730151572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730151572 NPI number — DENNIS M BRTVA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENNIS M BRTVA
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:
1730151572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2109 N VETERANS PKWY
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61704-0910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-663-2211
Provider Business Mailing Address Fax Number:
309-664-2971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2109 N VETERANS PKWY
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61704-0910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-663-2211
Provider Business Practice Location Address Fax Number:
309-664-2971
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRTVA
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
309-663-2211

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , 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: 05721380 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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