Basic Information
Provider Information | |||||||||
NPI: | 1992038640 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BLESSINGCARE CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ILLINI COMMUNTIY PHYSICIANS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1005 BROADWAY ST | ||||||||
Address2: |   | ||||||||
City: | QUINCY | ||||||||
State: | IL | ||||||||
PostalCode: | 623012834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172238400 | ||||||||
FaxNumber: | 2172239945 | ||||||||
Practice Location | |||||||||
Address1: | 640 W WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | PITTSFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 623631350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172852113 | ||||||||
FaxNumber: | 2172852989 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2009 | ||||||||
LastUpdateDate: | 03/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOORE | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE, CAO | ||||||||
AuthorizedOfficialTelephone: | 2172238400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BLESSINGCARE CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 282NC0060X |   |   | N |   | Hospitals | General Acute Care Hospital | Critical Access | 207P00000X | 0005132 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.