1184747313 NPI number — BLUE RIVER SERVICES, INC.

Table of content: WENN JEAN NG M.D. (NPI 1346452554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184747313 NPI number — BLUE RIVER SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIVER SERVICES, INC.
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:
1184747313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 547
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORYDON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47112-0547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-738-2408
Provider Business Mailing Address Fax Number:
812-738-6281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5771 E. SPEED RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILLTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-365-2451
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOWE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
812-738-2408

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , 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: 100385530 A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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