Basic Information
| Provider Information | |||||||||
| NPI: | 1801194592 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VITA CENTER FOR WOMEN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 544 W PERSHING RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178722400 | ||||||||
| FaxNumber: | 2178722401 | ||||||||
| Practice Location | |||||||||
| Address1: | 544 W PERSHING RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178722400 | ||||||||
| FaxNumber: | 2178722401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2011 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | PFEIFFER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2178722400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 036104247 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 036104247 | 05 | IL | MEDICAID |