1659749489 NPI number — MUNSTER PRIMARY CARE PC

Table of content: (NPI 1659749489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659749489 NPI number — MUNSTER PRIMARY CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MUNSTER PRIMARY CARE PC
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:
1659749489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5580
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VILLA PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60181-5305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-478-7201
Provider Business Mailing Address Fax Number:
708-221-6766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9731 PRAIRIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGHLAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46322-3616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-301-5212
Provider Business Practice Location Address Fax Number:
708-221-6766
Provider Enumeration Date:
09/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FAROOQUI
Authorized Official First Name:
ASIF
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
901-619-5629

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  01063801A , 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: 01063801A . This is a "LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com