1952473001 NPI number — DAVID M SKILLRUD MD LTD

Table of content: SUSAN JEAN VENUTO CRNA (NPI 1962485375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952473001 NPI number — DAVID M SKILLRUD MD LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID M SKILLRUD MD 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:
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:
1952473001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
652 W JACKSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61550-1536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-266-8880
Provider Business Mailing Address Fax Number:
309-266-8889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 FRANKLIN AVE
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61761-3592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-451-9500
Provider Business Practice Location Address Fax Number:
309-266-8889
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEST
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
309-266-8880

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0005732063 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 005145 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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