1366624728 NPI number — JERI DINE ANP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366624728 NPI number — JERI DINE ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DINE
Provider First Name:
JERI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GALLOWAY
Provider Other First Name:
JERI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366624728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEECH GROVE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46107-0100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-859-1090
Provider Business Mailing Address Fax Number:
317-859-3322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 ALBANY ST
Provider Second Line Business Practice Location Address:
SOUTH ENTRANCE GROUND FLOOR
Provider Business Practice Location Address City Name:
BEECH GROVE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46107-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-859-1090
Provider Business Practice Location Address Fax Number:
317-859-3322
Provider Enumeration Date:
11/28/2007

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: 363LA2200X , with the licence number:  71000423A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 71000423A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0011953-21 . This is a "NP CERTIFICATION" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000041022 . This is a "M PLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 35-4994904 . This is a "TID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00068634 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 11478722 . This is a "CAQH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 28065854A . This is a "RN LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 71000423B . This is a "CSR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000550394 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200307870 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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