1417040049 NPI number — JILL ANN RIDGE

Table of content: JILL ANN RIDGE (NPI 1417040049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417040049 NPI number — JILL ANN RIDGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIDGE
Provider First Name:
JILL
Provider Middle Name:
ANN
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:
STUDY
Provider Other First Name:
JILL
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, OTR, CHT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417040049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8501 HARCOURT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-875-9105
Provider Business Mailing Address Fax Number:
317-875-8638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8501 HARCOURT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-875-9105
Provider Business Practice Location Address Fax Number:
317-875-8638
Provider Enumeration Date:
10/02/2006

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: 225XH1200X , with the licence number:  31003075A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 31003075A , 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: 000000185049 . This is a "ANTHEM HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 062110023 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00708373 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200250070 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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