1114072964 NPI number — CITY OF ELKHART

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 1114072964 NPI number — CITY OF ELKHART

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF ELKHART
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:
1114072964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2122
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48193-1122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-926-6985
Provider Business Mailing Address Fax Number:
336-510-5894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 EAST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46516-3610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-253-0103
Provider Business Practice Location Address Fax Number:
574-522-1023
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EDGERTON
Authorized Official First Name:
SHAUN
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT CHIEF OF OPERATIONS
Authorized Official Telephone Number:
574-293-8931

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  0135 , 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: 000000199574 . This is a "BLUE CROSS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 590014821 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200269490A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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