1134237639 NPI number — PODIATRIC MEDICAL ASSOCIATES PC

Table of content: (NPI 1134237639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134237639 NPI number — PODIATRIC MEDICAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PODIATRIC MEDICAL ASSOCIATES 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:
1134237639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 W 89TH AVE
Provider Second Line Business Mailing Address:
SUITE E-1
Provider Business Mailing Address City Name:
MERRILLVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-736-8915
Provider Business Mailing Address Fax Number:
219-736-8928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 W 89TH AVE
Provider Second Line Business Practice Location Address:
SUITE E-1
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-736-8915
Provider Business Practice Location Address Fax Number:
219-736-8928
Provider Enumeration Date:
08/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRANDFIELD
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-736-8915

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  07000353A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 07000785A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 07000922A , 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: 000000084758 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200326020 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1089370001 . This is a "MEDICARE DMERC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000084756 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 480016271 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 480032400 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 480020342 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00000209276 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100148090 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100207960 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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