1306024203 NPI number — NORTHEAST INDIANA UROLOGY PC

Table of content: (NPI 1306024203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306024203 NPI number — NORTHEAST INDIANA UROLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST INDIANA UROLOGY PC
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:
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:
1306024203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2512 E DUPONT RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-1609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-436-6667
Provider Business Mailing Address Fax Number:
260-469-7437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 HIGH ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46733-2351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-436-6667
Provider Business Practice Location Address Fax Number:
260-469-7437
Provider Enumeration Date:
02/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRINKMAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
260-436-6667

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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