1568648830 NPI number — JAMES C MATTERN DC, PC

Table of content: JAMES C MATTERN DC, PC (NPI 1568648830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568648830 NPI number — JAMES C MATTERN DC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTERN
Provider First Name:
JAMES
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC, PC
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:
1568648830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1231 CUMBERLAND AVE #D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47906-1358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-463-7337
Provider Business Mailing Address Fax Number:
765-497-4393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1231 CUMBERLAND AVE #D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47906-1358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-463-7337
Provider Business Practice Location Address Fax Number:
765-497-4393
Provider Enumeration Date:
01/16/2008

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: 111N00000X , with the licence number:  08001204A , 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: 100232700A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 352009282001 . This is a "ANTHEM EIN W/SUFFIX" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 352009282100 . This is a "CARESOURCE MEDICAID MCP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 08001204A . This is a "STATE LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 350048296 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000092081 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 00630 . This is a "ANTHEM MEDICAID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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