1194570762 NPI number — TREVOR NICHOLAS TAYLOR PT, DPT

Table of content: (NPI 1679718316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194570762 NPI number — TREVOR NICHOLAS TAYLOR PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
TREVOR
Provider Middle Name:
NICHOLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
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:
1194570762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 N SENATE AVE UNIT 161
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46204-1246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3660 GUION RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46222-1691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-329-7017
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2024

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:  05014941A , 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: 1104259359 . This is a "ANTHEM PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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