1134133515 NPI number — MR. STEVEN GLEN METTERNICH PT

Table of content: MR. STEVEN GLEN METTERNICH PT (NPI 1134133515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134133515 NPI number — MR. STEVEN GLEN METTERNICH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
METTERNICH
Provider First Name:
STEVEN
Provider Middle Name:
GLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1134133515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3655 E MIRROR LAKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TERRE HAUTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47805-2138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-645-4071
Provider Business Mailing Address Fax Number:
866-920-2133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3655 E MIRROR LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47805-2138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-645-4071
Provider Business Practice Location Address Fax Number:
866-920-2133
Provider Enumeration Date:
07/28/2006

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: 225100000X , with the licence number:  070002318 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 05001152A , 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: 0001283001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 650005686 . This is a "RAILROAD MEDICARE UPIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 000-1232012 . This is a "BLUE CROSS-KINTIC-INDIVIDUAL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 356107600 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1232012 . This is a "BLUE CROSS 2010 KINETIC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 001541 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 010934666 . This is a "KINETIC TAX ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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