1063525616 NPI number — DR. RALPH MERRILL WETZEL M.DIV, S.T.M, D.MIN.

Table of content: DR. NEHA GANDHI MD (NPI 1457429045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063525616 NPI number — DR. RALPH MERRILL WETZEL M.DIV, S.T.M, D.MIN.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WETZEL
Provider First Name:
RALPH
Provider Middle Name:
MERRILL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.DIV, S.T.M, D.MIN.
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:
1063525616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4310 ARA DR
Provider Second Line Business Mailing Address:
P.O. BOX 286
Provider Business Mailing Address City Name:
WOODBURN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46797-9588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-493-3695
Provider Business Mailing Address Fax Number:
260-493-3322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 LAKE AVE
Provider Second Line Business Practice Location Address:
125-F
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-426-5431
Provider Business Practice Location Address Fax Number:
260-460-1402
Provider Enumeration Date:
08/17/2006

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: 171W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YP1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 8934521762 . This is a "DRIVER'S LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 27105178 . This is a "TPIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: BRANDY432 . This is a "MPIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P0500190 . This is a "SBA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: XZMXZ3084733 . This is a "BLUECROSS BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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