NPI Record of GACHUGU MEDICAL CLINIC NPI 1003414442

Nurse Practitioner in Wood River, IL

Complete NPI Record

Field Name Value Definition
NPI1003414442The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code2Code 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 EINUNAVAILThe Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
Provider Organization Name Legal Business NameGACHUGU MEDICAL CLINICThe name of the organization provider. If the provider is an organization, this is the legal business name.
Provider First Line Business Mailing Address1 E FERGUSON AVEThe first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Business Mailing Address City NameWOOD RIVERThe city name in the mailing address of the provider being identified.
Provider Business Mailing Address State NameILThe State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Business Mailing Address Postal Code620951903The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address Country Code If outside U S USThe country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider Business Mailing Address Telephone Number6189179464The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider First Line Business Practice Location Address1 E FERGUSON AVEThe 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 NameWOOD RIVERThe city name in the location address of the provider being identified.
Provider Business Practice Location Address State NameILThe State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code620951903The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S USThe country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number6182518138The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number6182518140The fax number associated with the location address of the provider being identified.
Provider Enumeration Date10/16/2020The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date10/23/2020The date that a record was last updated or changed.
Authorized Official Last NameNDUNGUThe last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First NameWILSONThe first name of the authorized official.
Authorized Official Middle NameGACHUGUThe middle name of the authorized official.
Authorized Official Title or PositionAUTHORIZED OFFICIAL/OWNERThe title or position of the authorized official.
Authorized Official Telephone Number6189179463The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1363L00000XCode designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 1Y
Is Organization SubpartN
Authorized Official Name Prefix TextMR.
Authorized Official Credential TextNP
Healthcare Provider Taxonomy Group 1193400000X SINGLE SPECIALTY GROUP
NPI Certification Date10/16/2020