=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295491744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVUS ILLINOIS SERVICE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2021
-----------------------------------------------------
Last Update Date | 01/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 N WALL ST
-----------------------------------------------------
City | KANKAKEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60901-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 159-357-2568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12766
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32591-2766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JOSHUA POOLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-285-8388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------