1861686099 NPI number — NORTHWEST INDIANA EYE ASSOCIATES, PC

Table of content: (NPI 1861686099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861686099 NPI number — NORTHWEST INDIANA EYE ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST INDIANA EYE ASSOCIATES, 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:
D/B/A LEWYCKYJ-TAGLIA-FELTON EYE CLINICS
Provider Other Organization Name Type Code:
3
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:
1861686099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 BURLINGTON BEACH RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALPARAISO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46383-1665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-462-0309
Provider Business Mailing Address Fax Number:
219-464-4291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 SUPERIOR AVE.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-4037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-934-0150
Provider Business Practice Location Address Fax Number:
219-934-0152
Provider Enumeration Date:
08/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEWYCKYJ
Authorized Official First Name:
MYRON
Authorized Official Middle Name:
I.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-462-0309

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100315020 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".