NPI |
1477849909 |
|
Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Employer Identification Number EIN |
|
The last name of the provider. If the provider is an individual, this is the legal name. |
Provider Organization Name Legal Business Name |
GATEWAY FOUNDATION, INC. |
The first name of the provider, if the provider
is an individual. |
Provider First Line Business Practice Location Address |
600 W. LINCOLN STREET |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Provider Second Line Business Practice Location Address |
EAST |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
CASEYVILLE |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
IL |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
62232 |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
6183453970 |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Fax Number |
6183453970 |
The fax number associated with the location
address of the provider being identified. |
Provider Enumeration Date |
6/23/2011 |
The fax number associated with the location
address of the provider being identified. |
Last Update Date |
12/22/2021 |
The date that a record was last updated or changed. |
Authorized Official Last Name |
RUSSELL |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official First Name |
LATINA |
The first name of the authorized official. |
Authorized Official Title or Position |
CONTRACT AND CRED SPECIALIST |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Authorized Official Telephone Number |
3126631130 |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Taxonomy Code 1 |
324500000X |
|
Provider License Number 1 |
A-0538-0044-A |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider License Number State Code 1 |
IL |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
Y |
|
Parent Organization LBN |
GATEWAY FOUNDATION, INC. |
|
Parent Organization TIN |
|
|
NPI Certification Date |
12/22/2021 |
|