1225035504 NPI number — KATHLEEN WALLACE APN

Table of content: KATHLEEN WALLACE APN (NPI 1225035504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225035504 NPI number — KATHLEEN WALLACE APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
KATHLEEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
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:
1225035504
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 W 22ND ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-1563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-573-5000
Provider Business Mailing Address Fax Number:
630-491-5472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 W 86TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410-7086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-791-1555
Provider Business Practice Location Address Fax Number:
219-791-1560
Provider Enumeration Date:
07/01/2005

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: 363L00000X , with the licence number:  71000826A , 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: 000000331131 . This is a "ANTHEM BCBS NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100082060 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200280140B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500012853 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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