1730363748 NPI number — ACTIVE PODIATRY PC

Table of content: (NPI 1730363748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730363748 NPI number — ACTIVE PODIATRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE PODIATRY 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:
1730363748
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 LAFAYETTE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRAWFORDSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47933-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-362-7200
Provider Business Mailing Address Fax Number:
765-362-4870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3850 SHORE DR STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46254-4693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-328-6622
Provider Business Practice Location Address Fax Number:
317-290-0094
Provider Enumeration Date:
12/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHAE
Authorized Official First Name:
YONG
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
317-245-6223

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  07000857A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: 07000857A , 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: 200178610 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000480680 . This is a "ANTHEM /BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".