Provider Demographics
NPI:1447200027
Name:OUTREACH MEDICAL, INC.
Entity Type:Organization
Organization Name:OUTREACH MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:UCHE
Authorized Official - Middle Name:
Authorized Official - Last Name:MBAKWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-786-3541
Mailing Address - Street 1:1123 7TH AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-8449
Mailing Address - Country:US
Mailing Address - Phone:309-786-3541
Mailing Address - Fax:309-786-4573
Practice Address - Street 1:1123 7TH AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-8449
Practice Address - Country:US
Practice Address - Phone:309-786-3541
Practice Address - Fax:309-786-4573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0578344Medicaid
IL=========001Medicaid
IL4933840001Medicare NSC