1265755136 NPI number — INDIANA STATE DEPARTMENT OF HEALTH

Table of content: (NPI 1265755136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265755136 NPI number — INDIANA STATE DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA STATE DEPARTMENT OF HEALTH
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:
1265755136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 W 16TH STREET
Provider Second Line Business Mailing Address:
SUTIE B
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46202-7804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-921-5500
Provider Business Mailing Address Fax Number:
317-927-7801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 W 16TH STREET
Provider Second Line Business Practice Location Address:
SUTIE B
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-7804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-921-5500
Provider Business Practice Location Address Fax Number:
317-927-7801
Provider Enumeration Date:
03/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LIU
Authorized Official First Name:
LIXIA
Authorized Official Middle Name:
Authorized Official Title or Position:
LABORATORY DIRECTOR
Authorized Official Telephone Number:
317-921-8509

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 15D0662599 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: (LPI):100284680A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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