1396811006 NPI number — MRS. MARGARET KATHLEEN BRONSON PT

Table of content: MRS. MARGARET KATHLEEN BRONSON PT (NPI 1396811006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396811006 NPI number — MRS. MARGARET KATHLEEN BRONSON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRONSON
Provider First Name:
MARGARET
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRYDEN
Provider Other First Name:
MARGARET
Provider Other Middle Name:
KATHLEEN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396811006
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11109 PARKVIEW PLAZA DR # 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11143 PARKVIEW PLAZA DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46845-1728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-266-7400
Provider Business Practice Location Address Fax Number:
260-266-7439
Provider Enumeration Date:
11/27/2006

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: 225100000X , with the licence number:  05008097A , 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: 156572 . This is a "MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 11456687 . This is a "CAQH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200443000A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: N242400 . This is a "HARMONY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 35179001202 . This is a "CARESOURCE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000314469 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1424 . This is a "PHP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 4423623 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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