1043307978 NPI number — NEIL WANGSTROM MD PC

Table of content: (NPI 1043307978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043307978 NPI number — NEIL WANGSTROM MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEIL WANGSTROM MD 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:
6
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:
1043307978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 DETROIT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA PORTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46350-2473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-325-3770
Provider Business Mailing Address Fax Number:
219-325-8181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 DETROIT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PORTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46350-2473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-325-3770
Provider Business Practice Location Address Fax Number:
219-325-8181
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENRICH
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
219-325-3770

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  01038858 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 231H00000X , with the licence number: 23002292A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 71001701A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 71001740A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100165330A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000105404 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200245050A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200482190 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100165330 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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