1598991879 NPI number — MRS. TERESA MATIAS PT

Table of content: MRS. TERESA MATIAS PT (NPI 1598991879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598991879 NPI number — MRS. TERESA MATIAS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATIAS
Provider First Name:
TERESA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EWING
Provider Other First Name:
TERESA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598991879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 ENTERPRISE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-8813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-575-1980
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2674 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKEGAN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60085-4917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-336-8089
Provider Business Practice Location Address Fax Number:
847-336-8079
Provider Enumeration Date:
06/01/2009

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:  2515-024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 070-005449 , 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: 539320005 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P01119496 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 859400055 . This is a "MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: IL6697002 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL6237007 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 205086005 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL6238007 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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