Provider Demographics
NPI:1366599854
Name:STEPHEN & FRED SHRADER PTR
Entity type:Organization
Organization Name:STEPHEN & FRED SHRADER PTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-268-4848
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:204 N. LOCUST ST
Mailing Address - City:ARCOLA
Mailing Address - State:IL
Mailing Address - Zip Code:61910-0277
Mailing Address - Country:US
Mailing Address - Phone:217-268-4848
Mailing Address - Fax:
Practice Address - Street 1:204 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:ARCOLA
Practice Address - State:IL
Practice Address - Zip Code:61910-1407
Practice Address - Country:US
Practice Address - Phone:217-268-4848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL670002341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2190002OtherBCBS NUMBER
IL=========001Medicaid
IL=========001Medicaid