1780747170 NPI number — DAVID A HIRSTIUS DO

Table of content: DAVID A HIRSTIUS DO (NPI 1780747170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780747170 NPI number — DAVID A HIRSTIUS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIRSTIUS
Provider First Name:
DAVID
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1780747170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1707 N 12TH ST
Provider Second Line Business Mailing Address:
BLDG 29M
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-222-9487
Provider Business Mailing Address Fax Number:
217-222-8578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1707 N 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-222-8641
Provider Business Practice Location Address Fax Number:
217-222-8578
Provider Enumeration Date:
12/18/2006

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: 207Q00000X , with the licence number:  036112783 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X , with the licence number: 036112783 , 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)

  • Identifier: P00211188 . This is a "RAIL ROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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