1033408257 NPI number — INDIANA PHYSICIAN MANAGEMENT-SALEM, LLC

Table of content: KATHLEEN LORRAINE TULLY PHD (NPI 1851119770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033408257 NPI number — INDIANA PHYSICIAN MANAGEMENT-SALEM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA PHYSICIAN MANAGEMENT-SALEM, LLC
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:
1033408257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7007 SOLUTION CTR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-591-9231
Provider Business Mailing Address Fax Number:
317-870-0499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 N SHELBY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47167-2304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-883-5881
Provider Business Practice Location Address Fax Number:
317-870-0499
Provider Enumeration Date:
03/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BICK
Authorized Official First Name:
STEWART
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-338-5053

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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