1245453190 NPI number — MITCHELL-JERDAN FUNERAL HOME LTD

Table of content: (NPI 1245453190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245453190 NPI number — MITCHELL-JERDAN FUNERAL HOME LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MITCHELL-JERDAN FUNERAL HOME 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:
MITCHELL-JERDAN AMBULANCE SERVICE
Provider Other Organization Name Type Code:
5
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:
1245453190
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 WABASH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTOON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61938-4142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-234-8828
Provider Business Mailing Address Fax Number:
217-258-0786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 WABASH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTOON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61938-4142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-234-8828
Provider Business Practice Location Address Fax Number:
217-258-0786
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JERDAN
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
217-234-8828

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  66792 , 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: 168847 . This is a "PERSONAL CARE INSURANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 590128024 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0001570051 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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