1790143683 NPI number — MIDWEST MOBILE ANESTHESIA CONSULTANTS, SC

Table of content: (NPI 1790143683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790143683 NPI number — MIDWEST MOBILE ANESTHESIA CONSULTANTS, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST MOBILE ANESTHESIA CONSULTANTS, SC
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:
1790143683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4128 W STONEWATER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61615-8852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-692-6572
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 W WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61520-2444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-692-6572
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
ADRIENNE
Authorized Official Middle Name:
YVETTE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-453-1379

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  042620313 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 042620313 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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