1619921558 NPI number — KNOX WINAMAC COMMUNITY HEALTH CENTERS, INC

Table of content: (NPI 1619921558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619921558 NPI number — KNOX WINAMAC COMMUNITY HEALTH CENTERS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KNOX WINAMAC COMMUNITY HEALTH CENTERS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1619921558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1520 S HEATON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOX
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46534-2393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-772-2188
Provider Business Mailing Address Fax Number:
574-772-2190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 S HEATON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOX
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46534-2393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-772-2188
Provider Business Practice Location Address Fax Number:
574-772-2190
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRITZ
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
574-772-2188

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  50000720A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X , with the licence number: 50000720A , 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: 000000083056 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200020860A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50000720A . This is a "CORPORATION LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200897290 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100225090 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 351301967 . This is a "TAX ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01024309A . This is a "WALTER FRITZ, M.D. LICENS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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