1336598358 NPI number — GREATLAND HEALTHCARE OF INDIANA INC.

Table of content: (NPI 1336598358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336598358 NPI number — GREATLAND HEALTHCARE OF INDIANA INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATLAND HEALTHCARE OF INDIANA 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:
6
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:
1336598358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-0141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-595-5081
Provider Business Mailing Address Fax Number:
219-513-9215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9616 INDIANAPOLIS BLVD FL 2
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
HIGHLAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46322-2637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-595-5081
Provider Business Practice Location Address Fax Number:
219-513-9215
Provider Enumeration Date:
06/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HASSAN
Authorized Official First Name:
MONSURU
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
219-595-5081

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 19-013891-1 . This is a "STATE LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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