1588779375 NPI number — DR. JERRY ALVIN DEARTH M.D.

Table of content: DR. JERRY ALVIN DEARTH M.D. (NPI 1588779375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588779375 NPI number — DR. JERRY ALVIN DEARTH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEARTH
Provider First Name:
JERRY
Provider Middle Name:
ALVIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1588779375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11109 PARKVIEW PLAZA DR # 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1701
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:
13410 MAIN ST
Provider Second Line Business Practice Location Address:
BOX 340
Provider Business Practice Location Address City Name:
GRABILL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46741-2001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-2481
Provider Business Practice Location Address Fax Number:
260-969-3067
Provider Enumeration Date:
08/20/2006

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:  01029438A , 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: 100055390 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000595570 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00698419 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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