1336336593 NPI number — PROGRESSIVE FAMILY FOOT CARE PC

Table of content: (NPI 1336336593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336336593 NPI number — PROGRESSIVE FAMILY FOOT CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE FAMILY FOOT CARE 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:
6
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:
1336336593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
966 W US HIGHWAY 30
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHERERVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46375-1551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-322-8894
Provider Business Mailing Address Fax Number:
219-322-0056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
966 W US HIGHWAY 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHERERVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46375-1551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-322-8894
Provider Business Practice Location Address Fax Number:
219-322-0056
Provider Enumeration Date:
10/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
219-322-8894

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  07000703 , 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: 000000088054 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 480015806 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100201670A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61100087 . This is a "BLUE SHIELD OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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