1790744555 NPI number — VICTORIA J BROCKHOUSE DO

Table of content: VICTORIA J BROCKHOUSE DO (NPI 1790744555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790744555 NPI number — VICTORIA J BROCKHOUSE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCKHOUSE
Provider First Name:
VICTORIA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1790744555
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2540 COLLEGE AND UNIVERSITY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61790-2540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-438-2956
Provider Business Mailing Address Fax Number:
309-438-3689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 W CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61701-2814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-567-1400
Provider Business Practice Location Address Fax Number:
309-557-1461
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  336.043935 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 036081580 , 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)

  • Identifier: 036081580 . This is a "STATE LIC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 833120 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036081580 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080040113 . This is a "RR MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CA2264 . This is a "RR MEDICARE GROUP PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 336043935 . This is a "CONT SUBS" identifier . This identifiers is of the category "OTHER".




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