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  7. NPI Record 1750353454

MEDICAL ASSOCIATES OF JERSEYVILLE, LTD.
Complete NPI Record 1750353454
Family Medicine in Jerseyville, IL


Overall Rating: 4 out of 5 stars

NPI Status: Active since February 06, 2006

Contact Information

270 MAPLE SUMMIT RD
MCDOW BUILDING
JERSEYVILLE, IL
ZIP 62052
Phone: (618) 498-7108
Fax: (618) 498-7919

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Table of Contents

  1. NPI
  2. Entity Type Code
  3. Employer Identification Number EIN
  4. Provider Organization Name Legal Business Name
  5. Provider First Line Business Mailing Address
  6. Provider Business Mailing Address City Name
  7. Provider Business Mailing Address State Name
  8. Provider Business Mailing Address Postal Code
  9. Provider Business Mailing Address Country Code If outside U S
  10. Provider Business Mailing Address Telephone Number
  11. Provider Business Mailing Address Fax Number
  12. Provider First Line Business Practice Location Address
  13. Provider Second Line Business Practice Location Address
  14. Provider Business Practice Location Address City Name
  15. Provider Business Practice Location Address State Name
  16. Provider Business Practice Location Address Postal Code
  17. Provider Business Practice Location Address Country Code If outside U S
  18. Provider Business Practice Location Address Telephone Number
  19. Provider Business Practice Location Address Fax Number
  20. Provider Enumeration Date
  21. Last Update Date
  22. Authorized Official Last Name
  23. Authorized Official First Name
  24. Authorized Official Middle Name
  25. Authorized Official Title or Position
  26. Authorized Official Telephone Number
  27. Healthcare Provider Taxonomy Code 1
  28. Healthcare Provider Primary Taxonomy Switch 1
  29. Healthcare Provider Taxonomy Code 2
  30. Healthcare Provider Primary Taxonomy Switch 2
  31. Healthcare Provider Taxonomy Code 3
  32. Healthcare Provider Primary Taxonomy Switch 3
  33. Other Provider Identifier 1
  34. Other Provider Identifier Type Code 1
  35. Other Provider Identifier State 1
  36. Other Provider Identifier Issuer 1
  37. Other Provider Identifier 2
  38. Other Provider Identifier Type Code 2
  39. Other Provider Identifier State 2
  40. Is Organization Subpart
  41. Authorized Official Name Prefix Text
  42. Authorized Official Credential Text
  43. Healthcare Provider Taxonomy Group 1
  44. Healthcare Provider Taxonomy Group 3

Complete NPI Dataset

This page represents the complete record for NPI 1750353454. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1750353454
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 2
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: UNAVAIL
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
The name of the organization provider. If the provider is an organization, this is the legal business name.
Provider First Line Business Mailing Address: PO BOX 364
The first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Business Mailing Address City Name: JERSEYVILLE
The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: IL
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Business Mailing Address Postal Code: 620520364
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address Country Code If outside U S : US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider Business Mailing Address Telephone Number: 6184987108
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider Business Mailing Address Fax Number: 6184987919
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address fax number’’.
Provider First Line Business Practice Location Address: 270 MAPLE SUMMIT RD
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Second Line Business Practice Location Address: MCDOW BUILDING
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: JERSEYVILLE
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: IL
The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 620522004
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 6184987108
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 6184987919
The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 2/6/2006
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 4/24/2008
The date that a record was last updated or changed.
Authorized Official Last Name: BENWARE
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: TERRY
The first name of the authorized official.
Authorized Official Middle Name: LYNN
The middle name of the authorized official.
Authorized Official Title or Position: PRACTICE MANAGER
The title or position of the authorized official.
Authorized Official Telephone Number: 6184987108
The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 207R00000X
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 1: N
Healthcare Provider Taxonomy Code 2: 261QR1300X
Healthcare Provider Primary Taxonomy Switch 2: N
Healthcare Provider Taxonomy Code 3: 207Q00000X
Healthcare Provider Primary Taxonomy Switch 3: Y
Other Provider Identifier 1: 042007207
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 1: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 1: IL
Other Provider Identifier Issuer 1: CORPORATE LICENSE
Other Provider Identifier 2: =========001
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 2: 05
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 2: IL
Is Organization Subpart: N
Authorized Official Name Prefix Text: MRS.
Authorized Official Credential Text: R.N.
Healthcare Provider Taxonomy Group 1: 193200000X MULTI-SPECIALTY GROUP
Healthcare Provider Taxonomy Group 3: 193200000X MULTI-SPECIALTY GROUP