1124278569 NPI number — MRS. MELISSA ANN GWIN NP-C

Table of content: MRS. MELISSA ANN GWIN NP-C (NPI 1124278569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124278569 NPI number — MRS. MELISSA ANN GWIN NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GWIN
Provider First Name:
MELISSA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
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:
1124278569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10330 N MERIDIAN ST # 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46290-1024
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:
8424 NAAB RD STE 2A
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:
46260-1966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-415-6300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2008

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: 363LF0000X , with the licence number:  71002825A , 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: 200937540 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000610495 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 12736891 . This is a "PHCS NUMBER / MULTIPLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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