Unknown Individual – Nurse Practitioner, NPI 1164784740

Nurse Practitioner

Unknown Individual is a healthcare provider. based in Herrin, Illinois. specializing in Nurse Practitioner. They hold a License No. 209009562 (IL). The NPI Number for Unknown Individual is 1164784740

Main info

Organization

Inactive

14 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1164784740

Phone

(618) 942-2171

Address

201 S 14th St

Deactivation Date

10 February 2022

Doctor Profile

Medical School Name

OTHER

Secondary Phone

6185490721

Graduation Year

2012 (14 years ago)

PAC ID

0547413031

Group Practice PAC ID

3678677390

Professional Enrollment ID

I20130111000429

Data current as of

20 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

Provider Addresses for Unknown Individual

201 S 14th St
Herrin, IL 629483631
Phone: (618) 942-2171
Fax: (618) 988-6166
Type: Location
2 S Hospital Dr
Murphysboro, IL 629663333
Phone: (618) 684-3156
Fax: (618) 684-1040
Type: Location
PO BOX 1105
INDIANAPOLIS, IN 462061105
Phone: (618) 457-5200
Fax: (618) 529-0568
Type: Mailing
405 W JACKSON ST
CARBONDALE, IL 629011462
Phone: (618) 549-0721
Fax: (618) 529-0479
Type: Location

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 62948)

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Provider's Procedures

Unknown Individual performs procedures in Nurse Practitioner. See the list of HCPCS codes below.

Specialty	Practice State	HCPCS Code	Description	Service Count	Beneficiary Count
NURSE PRACTITIONER	IL	90670	Pneumococcal vaccine for injection into muscle	27	27

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 3678677390View full group profile

Name	Specialty	State
DR. MUHAMMAD JAWAD POPALZAI	H E M A T O L O G Y/ O N C O L O G Y	IL
JESSIE NICOLE FOX	-	IL
KIMBERLY ANN KESER (CS-FNP)	Nurse Practitioner	MO
DR. JAMES NELSON MOCK (MD)	Emergency Medicine	IL
MRS. JAMIE HULTGREN (FNP-BC)	-	IL
DR. SAJJAD MUEED (M.D.)	N E U R O L O G Y	IL
KRISTINA MARIE POTANOS (MD)	General Surgery	IL
DR. GURVEEN PAL SINGH MALHOTRA (M.D.)	-	IL
DR. KURT MARTIN (M.D.)	Pediatric Medicine, Internal Medicine	IL
SAHITYA SETTYPALLI (M.D)	-	IL