1295991222 NPI number — MAPLEWOOD FAMILY MEDICINE, LLC

Table of content: (NPI 1295991222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295991222 NPI number — MAPLEWOOD FAMILY MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAPLEWOOD FAMILY MEDICINE, 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:
CHRISTOPHER J. BRETZ, M.D.
Provider Other Organization Name Type Code:
5
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:
1295991222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 626
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREMONT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46737-0626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-665-9100
Provider Business Mailing Address Fax Number:
260-665-9112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3270 INTERTECH DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ANGOLA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46703-7325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-665-9100
Provider Business Practice Location Address Fax Number:
260-665-9112
Provider Enumeration Date:
07/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRETZ
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PHYSICIAN - OWNER
Authorized Official Telephone Number:
260-665-9100

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01058292A , 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)

  • Identifier: 200508530A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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