1609806470 NPI number — HANCOCK PHYSICIAN NETWORK, LLC

Table of content: (NPI 1609806470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609806470 NPI number — HANCOCK PHYSICIAN NETWORK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HANCOCK PHYSICIAN NETWORK, 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:
1609806470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46140-0129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-468-6270
Provider Business Mailing Address Fax Number:
317-468-6268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
156 W MUSKEGON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46140-3069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-468-6260
Provider Business Practice Location Address Fax Number:
317-468-6267
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUCKERHEIDE
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
317-468-6236

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  70000074A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163W00000X , with the licence number: 28075482A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 01061823A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 01062448A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 01064501A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 01052168A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200311740D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200841490 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200853260 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01061823A . This is a "LICENSE NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01061823B . This is a "CSR NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1982757373 . This is a "NPI NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200311740 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111401698 . This is a "NPI NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1467485003 . This is a "NPI NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1548272289 . This is a "NPI NIMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000493483 . This is a "ANTHEM PIN NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01062448A . This is a "LICENSE NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 208M00000X . This is a "HOSPITALIST" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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