1285643205 NPI number — DR. DWIGHT S TYNDALL MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285643205 NPI number — DR. DWIGHT S TYNDALL MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

TYNDALL

Provider First Name:

DWIGHT

Provider Middle Name:

S

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1285643205

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/20/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

601 GATEWAY AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CHESTERTON

Provider Business Mailing Address State Name:

IN

Provider Business Mailing Address Postal Code:

46304

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

219-921-1444

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

500 E 109TH AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CROWN POINT

Provider Business Practice Location Address State Name:

IN

Provider Business Practice Location Address Postal Code:

46307-7294

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

219-921-1444

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

08/07/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207X00000X , with the licence number:  01051714A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207XS0117X , with the licence number: 01051714A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 5797564 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 140220 . This is a "MEDICARE GROUP SMMN" identifier . This identifiers is of the category "OTHER".
• Identifier: 001051714 . This is a "BCIL TYNDALL" identifier . This identifiers is of the category "OTHER".
• Identifier: 200135850A . This is a "MEDICAID IND GROUP" identifier . This identifiers is of the category "OTHER".
• Identifier: 874640 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 104771 . This is a "ANTHEM GROUP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 200226250A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: CI3318 . This is a "RRMEDICARE GROUP" identifier . This identifiers is of the category "OTHER".
• Identifier: 1160572 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 036095677 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
• Identifier: 00000092093 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
• Identifier: 90000692 . This is a "BCIL GROUP" identifier . This identifiers is of the category "OTHER".