1942757497 NPI number — WABASH GENERAL HOSPITAL PRIMARY CARE

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 1942757497 NPI number — WABASH GENERAL HOSPITAL PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WABASH GENERAL HOSPITAL PRIMARY CARE
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:
1942757497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 JAQUESS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT CARMEL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62863-1211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-262-2277
Provider Business Mailing Address Fax Number:
618-262-2281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 JAQUESS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT CARMEL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62863-1211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-262-2277
Provider Business Practice Location Address Fax Number:
618-262-2281
Provider Enumeration Date:
09/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
CLAY
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PHYSICIAN ASSISTANT
Authorized Official Telephone Number:
618-262-2277

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , 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)





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