1922145002 NPI number — JERRY L. BEGUELIN, MD, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922145002 NPI number — JERRY L. BEGUELIN, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERRY L. BEGUELIN, MD, PC
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:
6
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:
1922145002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62848-0190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-249-6203
Provider Business Mailing Address Fax Number:
618-249-6263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 HURON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-249-6203
Provider Business Practice Location Address Fax Number:
618-249-6263
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BEGUELIN
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-249-6203

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  36038738 ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QP2300X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 1245228881 . This is a "NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 36038738 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 333462458000 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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