Basic Information
Provider Information | |||||||||
NPI: | 1831156124 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE CARLE FOUNDATION HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CARLE MEDICAL SUPPLY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 611 W PARK | ||||||||
Address2: |   | ||||||||
City: | URBANA | ||||||||
State: | IL | ||||||||
PostalCode: | 61801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2173833311 | ||||||||
FaxNumber: | 2174461060 | ||||||||
Practice Location | |||||||||
Address1: | 311 W. FAIRCHILD | ||||||||
Address2: | SUITE C | ||||||||
City: | DANVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 618323940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2174460577 | ||||||||
FaxNumber: | 2174461060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2006 | ||||||||
LastUpdateDate: | 02/24/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEONARD | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2173833220 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CARLE FOUNDATION HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.