1417076506 NPI number — SUSAN CONLEY

Table of content: SUSAN CONLEY (NPI 1417076506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417076506 NPI number — SUSAN CONLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONLEY
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1417076506
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 MAIN ST
Provider Second Line Business Mailing Address:
STE. 450
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61602-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-672-4568
Provider Business Mailing Address Fax Number:
309-672-4569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 MAIN ST
Provider Second Line Business Practice Location Address:
STE. 450
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61602-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-672-4568
Provider Business Practice Location Address Fax Number:
309-672-4569
Provider Enumeration Date:
03/28/2007

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: 225100000X , with the licence number:  070-003842 , 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: P00987252 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 537460030 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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