1952514895 NPI number — SACRIS MEDICAL CORPORATION PC

Table of content: (NPI 1952514895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952514895 NPI number — SACRIS MEDICAL CORPORATION PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SACRIS MEDICAL CORPORATION 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:
1952514895
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1338
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:
46384-1338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-462-4042
Provider Business Mailing Address Fax Number:
219-462-1444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 ROOSEVELT RD
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46383-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-462-4042
Provider Business Practice Location Address Fax Number:
219-462-1444
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DELA VINA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
219-462-4042

Provider Taxonomy Codes

  • Taxonomy code: 207VH0002X , with the licence number:  01025728 , 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: 000000109115 . This is a "BLUE CROSS OF INDIANA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 90000239 . This is a "BLUE CROSS OF ILLINOIS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100076930A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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