1861692402 NPI number — MOBILE PODIATRIST, PC

Table of content: (NPI 1861692402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861692402 NPI number — MOBILE PODIATRIST, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOBILE PODIATRIST, 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:
1861692402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1558 VICTORIA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46143-7884
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-697-6536
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1558 VICTORIA CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46143-7884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-697-6536
Provider Business Practice Location Address Fax Number:
317-859-2923
Provider Enumeration Date:
07/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROGE
Authorized Official First Name:
IRENE
Authorized Official Middle Name:
ERICA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-697-6536

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  07001009A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213EP1101X , with the licence number: 016-004848 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DF0688 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: DE1825 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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