1295789980 NPI number — MR. PATRICK T CASEY PHD

Table of content: MR. PATRICK T CASEY PHD (NPI 1295789980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295789980 NPI number — MR. PATRICK T CASEY PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASEY
Provider First Name:
PATRICK
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1295789980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
314 W CATALPA
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
MISHAWAKA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-254-1700
Provider Business Mailing Address Fax Number:
574-254-2930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 W CATALPA
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-254-1700
Provider Business Practice Location Address Fax Number:
574-254-2930
Provider Enumeration Date:
05/19/2006

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: 103TC0700X , with the licence number:  20040647A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103G00000X , with the licence number: 6301010565 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100383345A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5170415 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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