1902901895 NPI number — MRS. JOLEEN DEE HARTLAND MS

Table of content: MRS. JOLEEN DEE HARTLAND MS (NPI 1902901895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902901895 NPI number — MRS. JOLEEN DEE HARTLAND MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARTLAND
Provider First Name:
JOLEEN
Provider Middle Name:
DEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS
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:
1902901895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 WILLOW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SLEEPY HOLLOW
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-428-4206
Provider Business Mailing Address Fax Number:
708-535-7571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 LAKE ST
Provider Second Line Business Practice Location Address:
502B
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-524-2655
Provider Business Practice Location Address Fax Number:
708-535-7571
Provider Enumeration Date:
09/14/2006

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: 101YP2500X , 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: 01673135 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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