Provider Demographics
NPI:1871584920
Name:OFFENBACK, RICHARD JR (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:OFFENBACK
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:CARDIOVASCULAR AND THORACIC SURGERY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-904-7000
Practice Address - Fax:217-904-7742
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085000765363A00000X
SC2540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL970008670Medicare ID - Type UnspecifiedRAILROAD#
K50806Medicare PIN
ILIL3270500Medicare PIN
S19186Medicare UPIN
IL6447860011Medicare NSC
ILL94547Medicare ID - Type UnspecifiedWPS MEDICARE
0533210001Medicare NSC
ILS19186Medicare UPIN