1356336788 NPI number — DR. KATHERINE L CASSIDY MD

Table of content: DR. KATHERINE L CASSIDY MD (NPI 1356336788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356336788 NPI number — DR. KATHERINE L CASSIDY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASSIDY
Provider First Name:
KATHERINE
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1356336788
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3640 NEW VISION DRIVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-482-4440
Provider Business Mailing Address Fax Number:
260-482-4442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 RANDALLIA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-4638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-373-4000
Provider Business Practice Location Address Fax Number:
260-482-4442
Provider Enumeration Date:
09/12/2005

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: 207P00000X , with the licence number:  01054605A , 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: 104874614 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000010974 . This is a "MPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 930113729 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000214697 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 047840VVV . This is a "MEDICARE WPS/CMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200364960 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2521284 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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