1053409623 NPI number — LORI E SIEBOLDT MD

Table of content: LORI E SIEBOLDT MD (NPI 1053409623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053409623 NPI number — LORI E SIEBOLDT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIEBOLDT
Provider First Name:
LORI
Provider Middle Name:
E
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:
LOWERY
Provider Other First Name:
LORI
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053409623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3407
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47733-3407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-450-3405
Provider Business Mailing Address Fax Number:
812-450-3099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 MARY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47747-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-450-3405
Provider Business Practice Location Address Fax Number:
812-450-3099
Provider Enumeration Date:
10/10/2006

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: 207P00000X , with the licence number:  01059205A , 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: 000000381085 . This is a "BCBS - GATEWAY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 097292 . This is a "HAMP PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 7197383 . This is a "AETNA PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000333639 . This is a "BCBS - MARY STREET" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200494470 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2244686 . This is a "FIRST HEALTH PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 64082910 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 681577 . This is a "HEALTHLINK PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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