1356336861 NPI number — AMBASSADOR HEALTHCARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356336861 NPI number — AMBASSADOR HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMBASSADOR HEALTHCARE, LLC
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:
1356336861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12953 PUBLISHERS DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
FISHERS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46038-8811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-577-2827
Provider Business Mailing Address Fax Number:
317-577-5933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47330-9676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-855-3424
Provider Business Practice Location Address Fax Number:
765-855-1087
Provider Enumeration Date:
09/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
K.
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
317-577-4150

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  050004561 , 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: 000000315404 . This is a "BC/BS PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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