Basic Information
Provider Information | |||||||||
NPI: | 1447512868 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIPE | ||||||||
FirstName: | ADAM | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3050 MONTVALE DR | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 627044290 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2177268096 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 500 S UNIVERSITY AVE STE 101 | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 72205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016643914 | ||||||||
FaxNumber: | 5016645246 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2012 | ||||||||
LastUpdateDate: | 12/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2017006926 | MO | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | E-11126 | AR | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 200041366 | 05 | MO |   | MEDICAID | 223065001 | 05 | AR |   | MEDICAID | ENROLLED | 05 | IL |   | MEDICAID |