1699703975 NPI number — SUSAN M DOUGLAS MD

Table of content: SUSAN M DOUGLAS MD (NPI 1699703975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699703975 NPI number — SUSAN M DOUGLAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGLAS
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1699703975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79430-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-743-6759
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2006

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: 207L00000X , with the licence number:  01052790A , 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: 000000207857 . This is a "BCBS PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 64041742 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000501000 . This is a "BCBS - DEACONESS GATEWAY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 300010735 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000001146552 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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