1326043597 NPI number — PETER GEORGE MAVRELIS MD

Table of content: PETER GEORGE MAVRELIS MD (NPI 1326043597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326043597 NPI number — PETER GEORGE MAVRELIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAVRELIS
Provider First Name:
PETER
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326043597
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7895 GRAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOBART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46342-6665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-947-1910
Provider Business Mailing Address Fax Number:
219-758-5009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7895 GRAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOBART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46342-6665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-947-1910
Provider Business Practice Location Address Fax Number:
219-758-5009
Provider Enumeration Date:
06/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  01030831A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000085027 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100138640A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9115389 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 110044491 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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