1609029214 NPI number — LASHAWN D FREEMAN DPM SC

Table of content: (NPI 1609029214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609029214 NPI number — LASHAWN D FREEMAN DPM SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LASHAWN D FREEMAN DPM SC
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:
1609029214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19468
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60619-0468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-882-2000
Provider Business Mailing Address Fax Number:
219-881-2836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 GRANT ST
Provider Second Line Business Practice Location Address:
#4
Provider Business Practice Location Address City Name:
GARY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46404-1533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-882-2000
Provider Business Practice Location Address Fax Number:
219-882-2044
Provider Enumeration Date:
10/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FREEMAN
Authorized Official First Name:
LASHAWN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-882-2000

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  07001023A , 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: 200901880A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD6800 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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