1265524383 NPI number — CENTRAL INDIANA OB/GYN, LLC

Table of content: (NPI 1265524383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265524383 NPI number — CENTRAL INDIANA OB/GYN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL INDIANA OB/GYN, 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:
1265524383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3111 W JACKSON ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MUNCIE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47304-4371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-288-2200
Provider Business Mailing Address Fax Number:
765-288-0913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3111 W JACKSON ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MUNCIE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47304-4371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-288-2200
Provider Business Practice Location Address Fax Number:
765-288-0913
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
765-729-4903

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01060775A . This is a "IN MEDICAL LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200522530 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01060775B . This is a "IN CDS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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