1790043750 NPI number — TRICARE MEDICAL GROUP OF MIDWEST

Table of content: (NPI 1790043750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790043750 NPI number — TRICARE MEDICAL GROUP OF MIDWEST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRICARE MEDICAL GROUP OF MIDWEST
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:
1790043750
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3535 E NEW YORK STREET
Provider Second Line Business Mailing Address:
SUITE 121
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60504-4427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-499-1900
Provider Business Mailing Address Fax Number:
630-499-1903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 E NEW YORK STREET
Provider Second Line Business Practice Location Address:
SUITE 119
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60504-4427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-499-1900
Provider Business Practice Location Address Fax Number:
630-499-1903
Provider Enumeration Date:
04/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SAYEED
Authorized Official First Name:
SIFATUR
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-499-1900

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  036094039 , 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: 036094039 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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