1326081894 NPI number — MARY LUEDTKE FNP

Table of content: MARY LUEDTKE FNP (NPI 1326081894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326081894 NPI number — MARY LUEDTKE FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUEDTKE
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

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:
1326081894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 GREEN RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-1598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-995-3764
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W HOMER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360-4358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-879-8511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2006

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: 363LF0000X , with the licence number:  71001174A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: ARNP9278988 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000302800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".