1396058608 NPI number — JACK E BONHAM PA

Table of content: JACK E BONHAM PA (NPI 1396058608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396058608 NPI number — JACK E BONHAM PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONHAM
Provider First Name:
JACK
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1396058608
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7112
Provider Second Line Business Mailing Address:
DPT 31
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46207-7112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-802-3151
Provider Business Mailing Address Fax Number:
317-870-0499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 ALBANY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEECH GROVE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46107-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-802-3151
Provider Business Practice Location Address Fax Number:
317-870-0499
Provider Enumeration Date:
07/16/2010

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: 363A00000X , with the licence number:  10001193A , 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: 300016938 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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