Provider Demographics
NPI:1316124159
Name:DAVID T ADE
Entity type:Organization
Organization Name:DAVID T ADE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-762-5515
Mailing Address - Street 1:550 30TH AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-5975
Mailing Address - Country:US
Mailing Address - Phone:309-762-5513
Mailing Address - Fax:309-762-5519
Practice Address - Street 1:550 30TH AVE STE 12
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5975
Practice Address - Country:US
Practice Address - Phone:309-762-5513
Practice Address - Fax:309-762-5519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15061Medicare UPIN