Basic Information
| Provider Information | |||||||||
| NPI: | 1356330005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGDAHL | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ENGDAHL | ||||||||
| OtherFirstName: | TODD | ||||||||
| OtherMiddleName: | LAWRENCE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 W DEYOUNG ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629595884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189987000 | ||||||||
| FaxNumber: | 6189976589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036113579 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036113579 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | E-14230 | AR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 35101 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.