1861686099 NPI number — NORTHWEST INDIANA EYE ASSOCIATES, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861686099 NPI number — NORTHWEST INDIANA EYE ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST INDIANA EYE ASSOCIATES, 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:
D/B/A LEWYCKYJ-TAGLIA-FELTON EYE CLINICS
Provider Other Organization Name Type Code:
3
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:
1861686099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 BURLINGTON BEACH RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALPARAISO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46383-1665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-462-0309
Provider Business Mailing Address Fax Number:
219-464-4291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 SUPERIOR AVE.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-4037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-934-0150
Provider Business Practice Location Address Fax Number:
219-934-0152
Provider Enumeration Date:
08/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEWYCKYJ
Authorized Official First Name:
MYRON
Authorized Official Middle Name:
I.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-462-0309

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100315020 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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