1568850113 NPI number — STACY L. ORDNER APN

Table of content: STACY L. ORDNER APN (NPI 1568850113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568850113 NPI number — STACY L. ORDNER APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORDNER
Provider First Name:
STACY
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GROVE
Provider Other First Name:
STACY
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568850113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 HEALTH CENTER DR STE 201
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:
61938-4693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-238-6055
Provider Business Mailing Address Fax Number:
217-258-2216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 HEALTH CENTER DR
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:
61938-9261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-238-4325
Provider Business Practice Location Address Fax Number:
217-348-4290
Provider Enumeration Date:
01/06/2015

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: 363LF0000X , with the licence number:  209012474 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: 209012474 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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