1265826226 NPI number — MARIO REMEDIOS ORTIZ PHD; PHCNS-BC, FNP-C

Table of content: MARIO REMEDIOS ORTIZ PHD; PHCNS-BC, FNP-C (NPI 1265826226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265826226 NPI number — MARIO REMEDIOS ORTIZ PHD; PHCNS-BC, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTIZ
Provider First Name:
MARIO
Provider Middle Name:
REMEDIOS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD; PHCNS-BC, FNP-C
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:
1265826226
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 MISHAWAKA AVE # SAC-130
Provider Second Line Business Mailing Address:
HEALTH & WELLNESS CENTER, IU SOUTH BEND
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46615-1408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-520-5557
Provider Business Mailing Address Fax Number:
574-520-5042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 MISHAWAKA AVE # SAC-130
Provider Second Line Business Practice Location Address:
HEALTH & WELLNESS CENTER, IU SOUTH BEND
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46615-1408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-520-5557
Provider Business Practice Location Address Fax Number:
574-520-5042
Provider Enumeration Date:
03/26/2015

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: 363LF0000X , with the licence number:  71005395A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SC1501X , with the licence number: 71005395A , 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)





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