Basic Information
| Provider Information | |||||||||
| NPI: | 1578536215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRVING | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| 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: | 02/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34419 | IA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036105497 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036105497002 | 05 | IL | MEDICAID | IA0101 | 01 | JOHN DEERE | OTHER | 0569475 | 05 | IL | MEDICAID | 2569475 | 05 | IL | MEDICAID | 12105 | 01 | BCWELLMARK TP | OTHER | 930126594 | 01 | RR MEDICARE | OTHER | 93230 | 01 | BCWELLMARK WEST | OTHER | IL0181 | 01 | JOHN DEERE ILLINOIS | OTHER | 210869 | 01 | IHS | OTHER | 93231 | 01 | BCWELLMARK 7TH ST | OTHER |