Basic Information
| Provider Information | |||||||||
| NPI: | 1184969420 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED SLEEP INSTITUTE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 459 | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629030459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183559970 | ||||||||
| FaxNumber: | 6183559972 | ||||||||
| Practice Location | |||||||||
| Address1: | 2731 WEST MAIN | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2012 | ||||||||
| LastUpdateDate: | 04/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | SHELTON | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | FACILITY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6185496378 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084S0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 036101704 | 05 | IL | MEDICAID |