1942276720 NPI number — HEIDI M LAKANEN MD

Table of content: HEIDI M LAKANEN MD (NPI 1942276720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942276720 NPI number — HEIDI M LAKANEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAKANEN
Provider First Name:
HEIDI
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1942276720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 W. WHITE RIVER BLVD.
Provider Second Line Business Mailing Address:
RCS PROVIDER ENROLLMENT: ATTN-DAWN HAMAKER
Provider Business Mailing Address City Name:
MUNCIE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47303-4988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-668-5621
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1809 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46989-9242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-998-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2006

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: 207R00000X , with the licence number:  01044755 , 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: 200101500 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00720113 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00968548 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00968548 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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