1083726293 NPI number — SERENA KORTEPETER BASKIN MD

Table of content: SERENA KORTEPETER BASKIN MD (NPI 1083726293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083726293 NPI number — SERENA KORTEPETER BASKIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASKIN
Provider First Name:
SERENA
Provider Middle Name:
KORTEPETER
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:
1083726293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6626 E 75TH ST
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8177 CLEARVISTA PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46256-1662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-621-7801
Provider Business Practice Location Address Fax Number:
317-621-7205
Provider Enumeration Date:
09/01/2006

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:  12862 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 01067146A , 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: 30205561 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 71029982 . This is a "CIGNA ID" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: AA47227 . This is a "HARVARD PILGRIM ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200966820 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01Y008991NH03 . This is a "ANTHEM ID - GRANTHAM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 4147497 . This is a "MVP ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01YP08991NH01 . This is a "ANTHEM ID - NLHP" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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