1427001742 NPI number — DAVID EUGENE FELLOWS PA-C

Table of content: DAVID EUGENE FELLOWS PA-C (NPI 1427001742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427001742 NPI number — DAVID EUGENE FELLOWS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FELLOWS
Provider First Name:
DAVID
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1427001742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2537 MOMENTUM PL
Provider Second Line Business Mailing Address:
EMERGENCY DEPARTMENT
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60689-5325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-205-8995
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5215 HOLY CROSS PKWY
Provider Second Line Business Practice Location Address:
EMERGENCY DEPARTMENT
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46545-1469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-335-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2006

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: 363AS0400X , with the licence number:  0894 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 10001321 , 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: 200572850B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000740513 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".