1578540522 NPI number — MR. LUKE GERARD NELLIGAN D.O.

Table of content: MS. KATHERINE KENNEDY LICSW (NPI 1992100374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578540522 NPI number — MR. LUKE GERARD NELLIGAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELLIGAN
Provider First Name:
LUKE
Provider Middle Name:
GERARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1578540522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 BRENDON WAY
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
ZIONSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46077-1961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-733-8780
Provider Business Mailing Address Fax Number:
866-246-1514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1329 WEST 96TH STREET
Provider Second Line Business Practice Location Address:
EXCELL FOR LIFE
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-660-0888
Provider Business Practice Location Address Fax Number:
317-660-0880
Provider Enumeration Date:
12/29/2005

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: 207Q00000X , with the licence number:  02001548 , 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: 000000520470 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000632914 . This is a "BC/BS PIKE MEDICAL" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 5428035 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100465550A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15D1069058 . This is a "CLIA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200856130 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 768544 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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