1164702924 NPI number — DR. GREGORY NICHOLAS ESSIG PH.D.

Table of content: DR. GREGORY NICHOLAS ESSIG PH.D. (NPI 1164702924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164702924 NPI number — DR. GREGORY NICHOLAS ESSIG PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESSIG
Provider First Name:
GREGORY
Provider Middle Name:
NICHOLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1164702924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3625 PARK PL W
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
MISHAWAKA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46545-3561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-282-1090
Provider Business Mailing Address Fax Number:
866-540-3094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3625 PARK PL W
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46545-3561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-282-1090
Provider Business Practice Location Address Fax Number:
866-540-3094
Provider Enumeration Date:
08/25/2011

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: 103TC1900X , with the licence number:  20042533A , 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: 12278137 . This is a "CAQH UNIVERSAL PROVIDER DATASOURCE" identifier . This identifiers is of the category "OTHER".




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