1558662791 NPI number — SERENITY MEDICAL CENTER LLC

Table of content: (NPI 1558662791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558662791 NPI number — SERENITY MEDICAL CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY MEDICAL CENTER LLC
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:
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:
1558662791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10765 LANTERN RD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
FISHERS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46038-3597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-621-4181
Provider Business Mailing Address Fax Number:
317-621-4182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10765 LANTERN RD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
FISHERS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46038-3597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-621-4181
Provider Business Practice Location Address Fax Number:
317-621-4182
Provider Enumeration Date:
11/04/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KHAN
Authorized Official First Name:
SYED
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-621-4181

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9657571 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 482287 . This is a "MANAGED HEALTH NETWORK (MHN)" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000691245 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".