1144215096 NPI number — PROFESSIONAL EMERGENCY PHYSICIANS PC

Table of content: (NPI 1144215096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144215096 NPI number — PROFESSIONAL EMERGENCY PHYSICIANS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL EMERGENCY PHYSICIANS 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:
PROFESSIONAL EMERGENCY PHYSICIANS INC
Provider Other Organization Name Type Code:
4
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:
1144215096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3640 NEW VISION DRIVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-482-4440
Provider Business Mailing Address Fax Number:
260-482-4442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 RANDALLIA DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-4638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-373-4000
Provider Business Practice Location Address Fax Number:
260-482-4442
Provider Enumeration Date:
09/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GUTWEIN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
260-482-4440

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0882335 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100050250C , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000101129 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 047840 . This is a "MEDICARE CMS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100050250 I , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100050250 J , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100050250D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100050250A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100050250F , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100050250 H , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100050250E , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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