1780934166 NPI number — DIRECTCARE PHYSICIAN SERVICES, S.C.

Table of content: (NPI 1780934166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780934166 NPI number — DIRECTCARE PHYSICIAN SERVICES, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIRECTCARE PHYSICIAN SERVICES, S.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:
1780934166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7117 CRIMSON RIDGE DR
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61107-6213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-316-8700
Provider Business Mailing Address Fax Number:
310-356-4935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7117 CRIMSON RIDGE DR
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61107-6213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-633-8099
Provider Business Practice Location Address Fax Number:
630-658-0543
Provider Enumeration Date:
09/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ECKBURG
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
815-751-6316

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; 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)





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