1245287697 NPI number — EAGLE HIGHLANDS SURGERY CENTER LLC

Table of content: (NPI 1245287697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245287697 NPI number — EAGLE HIGHLANDS SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE HIGHLANDS SURGERY CENTER LLC
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:
6
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:
1245287697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6850 PARKDALE PL
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:
46254-4670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-329-7209
Provider Business Mailing Address Fax Number:
317-329-7293

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6850 PARKDALE PL
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:
46254-4670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-329-7209
Provider Business Practice Location Address Fax Number:
317-329-7293
Provider Enumeration Date:
05/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOEGLIN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT, EHSC
Authorized Official Telephone Number:
317-562-5660

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200848180A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZJ7070 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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