1780663484 NPI number — DR. WALTER W VIRKUS M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780663484 NPI number — DR. WALTER W VIRKUS M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

VIRKUS

Provider First Name:

WALTER

Provider Middle Name:

W

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1780663484

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/23/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

250 N SHADELAND AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

INDIANAPOLIS

Provider Business Mailing Address State Name:

IN

Provider Business Mailing Address Postal Code:

46219-4959

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1801 N SENATE BLVD

Provider Second Line Business Practice Location Address:

STE 535

Provider Business Practice Location Address City Name:

INDIANAPOLIS

Provider Business Practice Location Address State Name:

IN

Provider Business Practice Location Address Postal Code:

46202-1204

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

317-963-1950

Provider Business Practice Location Address Fax Number:

317-963-1955

Provider Enumeration Date:

01/11/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207X00000X , with the licence number:  01071856A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207X00000X , with the licence number: 036102954 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207XX0801X , with the licence number: 01071856A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 036102954 2 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
• Identifier: 207073 . This is a "MEDICARE PTAN LOCALITY 15" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: P00286665 . This is a "RR MEDICARE ID#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: 1633878 . This is a "BCBS GROUP ID#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: 201127550 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 207067 . This is a "MEDICARE PTAN LOCALITY 16" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: DA4902 . This is a "RR MEDICARE PTAN #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: 7736149 . This is a "AETNA ID#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".