1871698035 NPI number — GALESBURG ORTHOPEDIC SERVICES, LTD

Table of content: (NPI 1871698035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871698035 NPI number — GALESBURG ORTHOPEDIC SERVICES, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GALESBURG ORTHOPEDIC SERVICES, LTD
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:
1871698035
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
834 N SEMINARY ST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
GALESBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61401-2852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-342-0194
Provider Business Mailing Address Fax Number:
309-342-9759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
834 N SEMINARY ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
GALESBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61401-2852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-342-0194
Provider Business Practice Location Address Fax Number:
309-342-9759
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FARROW
Authorized Official First Name:
JEANNETTE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINSRATOR
Authorized Official Telephone Number:
309-342-0194

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04815039 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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