1346443520 NPI number — STEPHEN RALPH RIBAUDO PC

Table of content: (NPI 1346443520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346443520 NPI number — STEPHEN RALPH RIBAUDO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN RALPH RIBAUDO 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:
1346443520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
229 RED COACH DR
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MISHAWAKA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46545-3195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-525-5852
Provider Business Mailing Address Fax Number:
574-252-5862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
229 RED COACH DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46545-3195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-525-5852
Provider Business Practice Location Address Fax Number:
574-252-5862
Provider Enumeration Date:
06/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RIBAUDO
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
RALPH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
574-252-5852

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  01034333 , 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: DG1929 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200886440A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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