1457684581 NPI number — KIM K SHIMONEK NP

Table of content: KIM K SHIMONEK NP (NPI 1457684581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457684581 NPI number — KIM K SHIMONEK NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIMONEK
Provider First Name:
KIM
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRANEY
Provider Other First Name:
KIM
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ACNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457684581
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 N SENATE BLVD # B233
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-962-5339
Provider Business Practice Location Address Fax Number:
317-962-2082
Provider Enumeration Date:
09/08/2009

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: 363LA2100X , with the licence number:  71002274A , 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: 201100240 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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