1053473306 NPI number — UNITED HEALTH SERVICES OF ST. JOSEPH COUNTY, INC.

Table of content: (NPI 1053473306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053473306 NPI number — UNITED HEALTH SERVICES OF ST. JOSEPH COUNTY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNITED HEALTH SERVICES OF ST. JOSEPH COUNTY, INC.
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:
1053473306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6910 N. MAIN ST. MAIL UNIT 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-247-6047
Provider Business Mailing Address Fax Number:
574-247-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6910 N MAIN ST UNIT 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANGER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46530-9681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-247-6047
Provider Business Practice Location Address Fax Number:
574-247-6060
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAINE
Authorized Official First Name:
BONITA
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
574-247-6047

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 237600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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