1366624728 NPI number — JERI DINE ANP

Table of content: JERI DINE ANP (NPI 1366624728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366624728 NPI number — JERI DINE ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DINE
Provider First Name:
JERI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GALLOWAY
Provider Other First Name:
JERI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366624728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEECH GROVE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46107-0100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-859-1090
Provider Business Mailing Address Fax Number:
317-859-3322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 ALBANY ST
Provider Second Line Business Practice Location Address:
SOUTH ENTRANCE GROUND FLOOR
Provider Business Practice Location Address City Name:
BEECH GROVE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46107-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-859-1090
Provider Business Practice Location Address Fax Number:
317-859-3322
Provider Enumeration Date:
11/28/2007

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: 363LA2200X , with the licence number:  71000423A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 71000423A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0011953-21 . This is a "NP CERTIFICATION" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000041022 . This is a "M PLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 35-4994904 . This is a "TID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00068634 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 11478722 . This is a "CAQH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 28065854A . This is a "RN LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 71000423B . This is a "CSR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000550394 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200307870 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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