1316990112 NPI number — MICHAEL C OVERDAHL MD

Table of content: MICHAEL C OVERDAHL MD (NPI 1316990112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316990112 NPI number — MICHAEL C OVERDAHL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OVERDAHL
Provider First Name:
MICHAEL
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1316990112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11109 PARKVIEW PLAZA DR # 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-266-6013
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11104 PARKVIEW CIRCLE DR
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46845-1672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-266-5260
Provider Business Practice Location Address Fax Number:
260-266-5269
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: 207RP1001X , with the licence number:  01042341 , 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: P00685770 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200015210 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000576774 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000670288 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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