1962576330 NPI number — RINA A PATEL MD

Table of content: RINA A PATEL MD (NPI 1962576330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962576330 NPI number — RINA A PATEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATEL
Provider First Name:
RINA
Provider Middle Name:
A
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:
1962576330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 S LEBANON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46052-2792
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-482-7005
Provider Business Mailing Address Fax Number:
765-483-2517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 S LEBANON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46052-2792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-482-7005
Provider Business Practice Location Address Fax Number:
765-483-2517
Provider Enumeration Date:
11/20/2006

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: 207Q00000X , with the licence number:  25MA07534400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 50765 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 01072716A , 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: 0041939 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34931400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: WI1755003 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: WI1755 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 300056527 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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