Basic Information
Provider Information | |||||||||
NPI: | 1467411009 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PANIAMOGAN | ||||||||
FirstName: | CALEB | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2701 17TH ST | ||||||||
Address2: |   | ||||||||
City: | ROCK ISLAND | ||||||||
State: | IL | ||||||||
PostalCode: | 612015351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3097795000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2701 17TH ST | ||||||||
Address2: |   | ||||||||
City: | ROCK ISLAND | ||||||||
State: | IL | ||||||||
PostalCode: | 612015351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3097795000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2006 | ||||||||
LastUpdateDate: | 10/20/2007 | ||||||||
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 | 207P00000X | 3665 | IA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X |   | IL | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2577783 | 05 | IA |   | MEDICAID | IL0181 | 01 |   | JOHN DEERE ILLINOIS | OTHER | 99291 | 01 |   | BCWELLMARK WEST | OTHER | 1577783 | 05 | IA |   | MEDICAID | 503523 | 01 |   | IHS | OTHER | 99286 | 01 |   | BCWELLMARK 7TH | OTHER | 0577783 | 05 | IA |   | MEDICAID |