1093965501 NPI number — PREMIER HOSPITALIST PC

Table of content: (NPI 1093965501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093965501 NPI number — PREMIER HOSPITALIST PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER HOSPITALIST PC
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:
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:
1093965501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROWN POINT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46308-1047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-288-3452
Provider Business Mailing Address Fax Number:
708-401-0050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 GRANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46402-6001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-288-3452
Provider Business Practice Location Address Fax Number:
708-401-0050
Provider Enumeration Date:
09/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PALMER
Authorized Official First Name:
EMERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
708-288-3452

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  01049154 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: 01049154 , 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: 200289700 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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