=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841799848
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY CHRISTOPHER VERCRUYSSE PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2018
-----------------------------------------------------
Last Update Date | 09/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 845 S ROUTE 51
-----------------------------------------------------
City | FORSYTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-872-0953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 845 S ROUTE 51
-----------------------------------------------------
City | FORSYTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62535-9809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-872-0953
-----------------------------------------------------
Fax | 217-872-2056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------