1336334796 NPI number — SIGMA MEDICAL GROUP, LLC

Table of content: (NPI 1336334796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336334796 NPI number — SIGMA MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIGMA MEDICAL GROUP, LLC
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:
RENE S GUTIERREZ, MD
Provider Other Organization Name Type Code:
3
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:
1336334796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1415 SALEM ST
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47904-4100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-449-2410
Provider Business Mailing Address Fax Number:
765-742-8607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 FOXWOOD CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47960-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-583-2495
Provider Business Practice Location Address Fax Number:
574-583-2319
Provider Enumeration Date:
09/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCHMIDT
Authorized Official First Name:
LOIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
765-449-2410

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  01042516A , 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: 200495560 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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