1063530178 NPI number — INDIANA SKIN CANCER CENTER PC

Table of content: (NPI 1063530178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063530178 NPI number — INDIANA SKIN CANCER CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA SKIN CANCER CENTER 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:
1063530178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 NEW HAMPSHIRE AVE STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03801-2864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-909-2053
Provider Business Mailing Address Fax Number:
330-965-9325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 EAST COUNTY LINE RD
Provider Second Line Business Practice Location Address:
STE 208
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-859-8970
Provider Business Practice Location Address Fax Number:
317-859-8977
Provider Enumeration Date:
03/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MURPHY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
317-781-3604

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  01063061A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X , with the licence number: 01063061A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X , with the licence number: 01063061A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000000517792 . This is a "ANTHEM PROVIDER ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1164580973 . This is a "INDIVIDUAL NPI NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".