1922092931 NPI number — DR. GARY STANLEY STOUDER

Table of content: DR. GARY STANLEY STOUDER (NPI 1922092931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922092931 NPI number — DR. GARY STANLEY STOUDER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOUDER
Provider First Name:
GARY
Provider Middle Name:
STANLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1922092931
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2010
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:
8535 NORTH CLEARVIEW DRIVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MCCORDSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46055-6055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-335-6960
Provider Business Practice Location Address Fax Number:
317-335-5031
Provider Enumeration Date:
09/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01027577A , 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: 4072302 . This is a "AETNA PIN #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200311740J,G . This is a "MEDICAID GROUP#/LOCATION" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100350300 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000396462 . This is a "ANTHEM PIN #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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