=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720590045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEP AMERICA - ILLINOIS SNF, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2017
-----------------------------------------------------
Last Update Date | 10/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 S 3RD ST
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62220-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-234-2120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 POWELL ST STE 900
-----------------------------------------------------
City | EMERYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94608-1844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-350-2680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE VP OF OPERATIONS
-----------------------------------------------------
Name | DAVID BIRDSALL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 510-350-2680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------