1659342079 NPI number — DR. RAUL G ENAD M.D.

Table of content: DR. RAUL G ENAD M.D. (NPI 1659342079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659342079 NPI number — DR. RAUL G ENAD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENAD
Provider First Name:
RAUL
Provider Middle Name:
G
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:
1659342079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2675 WINKLER AVE
Provider Second Line Business Mailing Address:
FL 2
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33901-9342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-528-4800
Provider Business Mailing Address Fax Number:
317-865-1479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 S. MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307-8481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-757-6121
Provider Business Practice Location Address Fax Number:
219-681-6867
Provider Enumeration Date:
02/01/2006

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: 207R00000X , with the licence number:  01071642A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 2005031797 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 01071642A , 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: P01122801 . This is a "MEDICARE RR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201116290 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 616679523 . This is a "DEPARTMENT OF LABOR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 114362000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".