1346087053 NPI number — TARA EUGENIA MATHIS

Table of content: TARA EUGENIA MATHIS (NPI 1346087053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346087053 NPI number — TARA EUGENIA MATHIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHIS
Provider First Name:
TARA
Provider Middle Name:
EUGENIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1346087053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20200 MILLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46614-9432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-367-0395
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1657 COMMERCE DR STE 8B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46628-1542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-367-0395
Provider Business Practice Location Address Fax Number:
844-894-8398
Provider Enumeration Date:
07/10/2024

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: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 61-1857998 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61-1857998 . This is a "INTERNAL REVENUE SERVICES" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com