1477620508 NPI number — SINTAHYU MULATA CRNA

Table of content: SINTAHYU MULATA CRNA (NPI 1477620508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477620508 NPI number — SINTAHYU MULATA CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULATA
Provider First Name:
SINTAHYU
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

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:
1477620508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11456 SOUTH BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROWN POINT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46307-7106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-948-8015
Provider Business Mailing Address Fax Number:
219-661-1408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11456 SOUTH BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307-7106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-948-8015
Provider Business Practice Location Address Fax Number:
219-661-1408
Provider Enumeration Date:
11/30/2006

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: 367500000X , with the licence number:  28074199A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 430060834 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000189991 . This is a "BCBS OF INDIANA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 209003179 . This is a "BCBSIL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 20043140A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".