1891845418 NPI number — MEDSPA WOMANS HEALTHCARE PC

Table of content: (NPI 1891845418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891845418 NPI number — MEDSPA WOMANS HEALTHCARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSPA WOMANS HEALTHCARE 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:
1891845418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9721
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MICHIGAN CITY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46361-9721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-362-4690
Provider Business Mailing Address Fax Number:
219-362-4692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 KIEFFER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MICHIGAN CITY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-879-6262
Provider Business Practice Location Address Fax Number:
219-874-1885
Provider Enumeration Date:
01/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
JULIUS
Authorized Official Middle Name:
RODNEY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-362-4690

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  01052711A , 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)