Basic Information
Provider Information | |||||||||
NPI: | 1245483908 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOEBLER | ||||||||
FirstName: | ANTHONY | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1435 N RANDALL RD | ||||||||
Address2: | SUITE 103 | ||||||||
City: | ELGIN | ||||||||
State: | IL | ||||||||
PostalCode: | 601232306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478880750 | ||||||||
FaxNumber: | 8478882152 | ||||||||
Practice Location | |||||||||
Address1: | 1435 N RANDALL RD | ||||||||
Address2: | SUITE 103 | ||||||||
City: | ELGIN | ||||||||
State: | IL | ||||||||
PostalCode: | 601232306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478880750 | ||||||||
FaxNumber: | 8478882152 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2008 | ||||||||
LastUpdateDate: | 02/21/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X |   |   | Y |   | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
ID Information
ID | Type | State | Issuer | Description | 057551 | 01 | IL | NATIONAL CERTIFICATION | OTHER |