1932396157 NPI number — CENTRUM CARDIOLOGY, LTD

Table of content: (NPI 1932396157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932396157 NPI number — CENTRUM CARDIOLOGY, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRUM CARDIOLOGY, 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:
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:
1932396157
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
319 E MADISON ST STE 2D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62701-3120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-546-0750
Provider Business Mailing Address Fax Number:
217-546-0894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 E MADISON ST STE 2D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62701-3120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-546-0750
Provider Business Practice Location Address Fax Number:
217-546-0894
Provider Enumeration Date:
10/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
RANDOLPH
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
217-546-0750

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  036079474 , 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: 08432108 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 823599 . This is a "FIRST HEALTH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00140870 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 9683056002 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 008092 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 133621 . This is a "HEALTHLINK, INC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036079474 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 222623 . This is a "COVENTRY HEATH CARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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