1912083155 NPI number — DR. THADDEUS R WEGHORST MD

Table of content: DR. THADDEUS R WEGHORST MD (NPI 1912083155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912083155 NPI number — DR. THADDEUS R WEGHORST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEGHORST
Provider First Name:
THADDEUS
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1912083155
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6920 POINTE INVERNESS WAY STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-7934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-927-0035
Provider Business Mailing Address Fax Number:
260-927-0036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 SMALTZ WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46706-0612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-927-0035
Provider Business Practice Location Address Fax Number:
260-927-0036
Provider Enumeration Date:
10/31/2006

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: 207VX0000X , with the licence number:  01057752A , 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: 200427390 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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