1114941739 NPI number — NEUROLOGY CLINIC OF INDIANA, PC

Table of content: (NPI 1114941739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114941739 NPI number — NEUROLOGY CLINIC OF INDIANA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLOGY CLINIC OF INDIANA, 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:
1114941739
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 635361
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-0043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-870-6704
Provider Business Mailing Address Fax Number:
317-870-0499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8330 NAAB RD
Provider Second Line Business Practice Location Address:
SUITE #102
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46260-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-870-6704
Provider Business Practice Location Address Fax Number:
317-870-0499
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WANG
Authorized Official First Name:
WEI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-870-6704

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  01055906 , 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: 200828640 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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