1871705368 NPI number — PLATINUM FAMILY MEDICINE SC.

Table of content: (NPI 1871705368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871705368 NPI number — PLATINUM FAMILY MEDICINE SC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLATINUM FAMILY MEDICINE 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:
1871705368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1012 95TH ST
Provider Second Line Business Mailing Address:
SUITE 9
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60564-5041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-689-4944
Provider Business Mailing Address Fax Number:
630-717-0981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1012 95TH ST
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60564-5041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-689-4944
Provider Business Practice Location Address Fax Number:
630-717-0981
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SUTTON
Authorized Official First Name:
CLAIRE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
630-689-4944

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  042619030 , 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: 2233203 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 042619030 . This is a "MED CORP REGISTRATION" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DG5143 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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