1215266424 NPI number — MICHAEL JUSTISS

Table of content: MICHAEL JUSTISS (NPI 1215266424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215266424 NPI number — MICHAEL JUSTISS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUSTISS
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1215266424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12212 ALDENHAM BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FISHERS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46037-8472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-466-1000
Provider Business Mailing Address Fax Number:
317-466-2000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4740 KINGSWAY DR
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:
46205-1521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-466-1000
Provider Business Practice Location Address Fax Number:
317-466-2000
Provider Enumeration Date:
12/17/2009

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: 225X00000X , with the licence number:  31004386A , 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)