1558366153 NPI number — DR. CARRIE SHAFFER DO

Table of content: DR. CARRIE SHAFFER DO (NPI 1558366153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558366153 NPI number — DR. CARRIE SHAFFER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAFFER
Provider First Name:
CARRIE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1558366153
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1040 SIERRA DR
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46143-7241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-528-4284
Provider Business Mailing Address Fax Number:
317-865-8355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307-8481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-757-6446
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2005

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: 207P00000X , with the licence number:  02002783A , 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: 200497510 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000717646 . This is a "ANTHEM TRADITIONAL" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".