Basic Information
Provider Information | |||||||||
NPI: | 1942312442 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALTON MULTISPECIALISTS, LTD. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 PROFESSIONAL DR | ||||||||
Address2: |   | ||||||||
City: | ALTON | ||||||||
State: | IL | ||||||||
PostalCode: | 620025068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6184638500 | ||||||||
FaxNumber: | 6184740130 | ||||||||
Practice Location | |||||||||
Address1: | 1 PROFESSIONAL DR | ||||||||
Address2: |   | ||||||||
City: | ALTON | ||||||||
State: | IL | ||||||||
PostalCode: | 620025068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6184638500 | ||||||||
FaxNumber: | 6184740130 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 08/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HENSON | ||||||||
AuthorizedOfficialFirstName: | SHERRI | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6184638634 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-071248 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 261QR0206X | 100867 | IL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography |
ID Information
ID | Type | State | Issuer | Description | 207219 | 01 | IL | PTAN | OTHER | 0317160001 | 01 |   | MEDICARE DME SUPPLIER | OTHER | 687340 | 01 | IL | PTAN | OTHER | 06015403 | 01 | IL | BLUE CROSS/BLUE SHIELD | OTHER |