1083802987 NPI number — MARY A WENTZEL N.P.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083802987 NPI number — MARY A WENTZEL N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENTZEL
Provider First Name:
MARY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

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:
1083802987
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 781076
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48278-1076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-528-4800
Provider Business Mailing Address Fax Number:
317-865-1479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2451 INTELLIPLEX DR STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46176-8581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-893-1900
Provider Business Practice Location Address Fax Number:
317-398-1849
Provider Enumeration Date:
10/05/2007

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: 363L00000X , with the licence number:  71002325A , 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: 200938960 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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