1952539280 NPI number — DR. JEROME TAYMON DOMZALSKI MD

Table of content: (NPI 1588580492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952539280 NPI number — DR. JEROME TAYMON DOMZALSKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMZALSKI
Provider First Name:
JEROME
Provider Middle Name:
TAYMON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1952539280
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 OAKWOOD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61611-1853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-740-4272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 NE GLEN OAK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61637-4748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-655-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2009

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: 2085R0202X , with the licence number:  MD185931 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: MD60808674 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: M-14669 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 036-164444 , 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: 0384868 . This is a "LNI TRA-MINW, PS REST OF WA COUNTIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0384886 . This is a "LNI DINW" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0408166 . This is a "LNI RADIA REST OF WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0384879 . This is a "LNI TRA-MINW, PS KING COUNTY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0408173 . This is a "LNI EVERGREEN RADIA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2094399 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0384883 . This is a "LNI UAOM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0408171 . This is a "LNI SWEDISH RADIA EDMONDS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0408174 . This is a "LNI SOUTH SOUND RADIOLOGY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0408176 . This is a "LNI SEATTLE RADIOLOGY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0408168 . This is a "LNI RADIA KING COUNTY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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