1629011424 NPI number — DR. CLAYTON BRENNAN FITZPATRICK M.D.

Table of content: DR. CLAYTON BRENNAN FITZPATRICK M.D. (NPI 1629011424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629011424 NPI number — DR. CLAYTON BRENNAN FITZPATRICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZPATRICK
Provider First Name:
CLAYTON
Provider Middle Name:
BRENNAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1629011424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4199 GATEWAY BLVD
Provider Second Line Business Mailing Address:
SUITE 3100
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47630-8940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-842-4550
Provider Business Mailing Address Fax Number:
812-842-4549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4199 GATEWAY BLVD.
Provider Second Line Business Practice Location Address:
SUITE 3100
Provider Business Practice Location Address City Name:
NEWBURGH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-842-4550
Provider Business Practice Location Address Fax Number:
812-842-4549
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: 207VM0101X , with the licence number:  2005-00676 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VM0101X , with the licence number: 01056421A , 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: 200921290 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5901314 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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