1811993405 NPI number — JOHN C. KEFALAS, M.D.,S.C.

Table of content: (NPI 1811993405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811993405 NPI number — JOHN C. KEFALAS, M.D.,S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN C. KEFALAS, M.D.,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:
CENTRAL ILLINOIS BONE AND JOINT CENTER
Provider Other Organization Name Type Code:
3
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:
1811993405
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2905 N MAIN ST
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62526-4276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-425-2600
Provider Business Mailing Address Fax Number:
217-425-2900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2905 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62526-4276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-425-2600
Provider Business Practice Location Address Fax Number:
217-425-2900
Provider Enumeration Date:
06/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KEFALAS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
CHRIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
217-425-2600

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  36-094691 , 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: 36-094691 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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