1679601132 NPI number — NORTHERN INDIANA ORTHOPAEDICS, PC

Table of content: (NPI 1679601132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679601132 NPI number — NORTHERN INDIANA ORTHOPAEDICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN INDIANA ORTHOPAEDICS, PC
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:
1679601132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMOTTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46310-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-947-5606
Provider Business Mailing Address Fax Number:
219-942-4742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 S LAKE PARK AVE STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOBART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46342-6636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-947-5606
Provider Business Practice Location Address Fax Number:
219-942-4742
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FEDOR
Authorized Official First Name:
GENE
Authorized Official Middle Name:
VICTOR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-947-5606

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  01043359A , 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: 000000184715 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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