1497060511 NPI number — AMY M BOBALIK R.D.

Table of content: AMY M BOBALIK R.D. (NPI 1497060511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497060511 NPI number — AMY M BOBALIK R.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOBALIK
Provider First Name:
AMY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.D.
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:
1497060511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1234 E DUPONT RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-1545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-373-9700
Provider Business Mailing Address Fax Number:
260-373-9740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 MATCHETT DR
Provider Second Line Business Practice Location Address:
US HWY 30 W
Provider Business Practice Location Address City Name:
PIERCETON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46562-9073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-594-2136
Provider Business Practice Location Address Fax Number:
574-594-2281
Provider Enumeration Date:
08/12/2010

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: 133V00000X , with the licence number:  37001977A , 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: 000000675220 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000675210 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000675021 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com