1598725103 NPI number — PSG SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598725103 NPI number — PSG SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSG SERVICES, LLC
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:
DBA INTERIM HEALTHCARE
Provider Other Organization Name Type Code:
3
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:
1598725103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12855 S CICERO AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ALSIP
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60803-3043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-422-2934
Provider Business Mailing Address Fax Number:
708-422-5528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12855 S CICERO AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ALSIP
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60803-3043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-422-2934
Provider Business Practice Location Address Fax Number:
708-422-5528
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BULGER
Authorized Official First Name:
BERNARD
Authorized Official Middle Name:
D
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
708-422-2934

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1010247 , 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: N306219 . This is a "WELLCARE PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5215621 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2154 . This is a "PROF BUSINESS ADM" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 50180 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 000002649 . This is a "HUMANA PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 37144249001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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