1205041340 NPI number — INDIANA BACK CENTER PC

Table of content: (NPI 1205041340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205041340 NPI number — INDIANA BACK CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA BACK CENTER 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:
1205041340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13450 N MERIDIAN ST
Provider Second Line Business Mailing Address:
STE 244
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032-1546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-846-4484
Provider Business Mailing Address Fax Number:
317-571-2344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13450 N MERIDIAN ST
Provider Second Line Business Practice Location Address:
STE 244
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46032-1546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-846-4484
Provider Business Practice Location Address Fax Number:
317-571-2344
Provider Enumeration Date:
05/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHAY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
317-846-4484

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  01039661 , 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: 1255375994 . This is a "PHYSICIAN INDIVIDUAL NPI" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com