1750410726 NPI number — ILLINOIS ANESTHESIA COVERAGE P.C.

Table of content: (NPI 1750410726)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750410726 NPI number — ILLINOIS ANESTHESIA COVERAGE P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS ANESTHESIA COVERAGE P.C.
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:
1750410726
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7048
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61826-7048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-352-8947
Provider Business Mailing Address Fax Number:
217-352-8947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4010 RIVERKNOLL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61822-9213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-352-8947
Provider Business Practice Location Address Fax Number:
217-352-8947
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WELLINGHOFF
Authorized Official First Name:
JEROME
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
217-352-8947

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  209 001163 , 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: CG3273 . This is a "MEDICARE, RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: A001 . This is a "TRICARE MILITARY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 092-253-24 . This is a "BLUE CROSS BLUE SHIELD IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com