1063404002 NPI number — THOMAS L WHITTAKER MD

Table of content: THOMAS L WHITTAKER MD (NPI 1063404002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063404002 NPI number — THOMAS L WHITTAKER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITTAKER
Provider First Name:
THOMAS
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1063404002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6330 E 75TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-594-6900
Provider Business Mailing Address Fax Number:
317-594-6911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE MEMORIAL SQ
Provider Second Line Business Practice Location Address:
STE 50
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46140-1357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-467-7100
Provider Business Practice Location Address Fax Number:
317-467-0209
Provider Enumeration Date:
08/16/2005

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: 207RX0202X , with the licence number:  01041624 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0000X , with the licence number: 01041624 , 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: 900000282 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100323710 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01055080 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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