Basic Information
Provider Information | |||||||||
NPI: | 1003813601 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAULK | ||||||||
FirstName: | EDDIE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6810 STATE ROUTE 162 BOX 215 | ||||||||
Address2: |   | ||||||||
City: | MARYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 620628501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183916405 | ||||||||
FaxNumber: | 6182884088 | ||||||||
Practice Location | |||||||||
Address1: | 2090 VADALABENE DRIVE | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 62062 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182885403 | ||||||||
FaxNumber: | 6182886857 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2005 | ||||||||
LastUpdateDate: | 04/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R9H10 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208D00000X | R9H10 | MO | N |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 242830743 | 05 | MO |   | MEDICAID |