1992845358 NPI number — MID-CENTRAL ILL GASTRO

Table of content: (NPI 1992845358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992845358 NPI number — MID-CENTRAL ILL GASTRO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-CENTRAL ILL GASTRO
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:
1992845358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 JACOBSSEN DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
NORMAL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61761-5516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-451-1123
Provider Business Mailing Address Fax Number:
309-451-1212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 JACOBSSEN DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61761-5516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-451-1123
Provider Business Practice Location Address Fax Number:
309-451-1212
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATTER
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-451-1123

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0360818161 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05725403 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0360788251 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com