1508191768 NPI number — ALLIED PHYSICIANS OF MICHIANA, LLC

Table of content: (NPI 1508191768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508191768 NPI number — ALLIED PHYSICIANS OF MICHIANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLIED PHYSICIANS OF MICHIANA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1508191768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6301 UNIVERSITY COMMONS
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46635-1571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-251-2100
Provider Business Mailing Address Fax Number:
574-251-2150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 MEMORIAL DR
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46601-1063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-236-1888
Provider Business Practice Location Address Fax Number:
574-236-1887
Provider Enumeration Date:
10/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ROUSSARIE
Authorized Official First Name:
SHERY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
574-251-2100

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200962980G , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200962980V , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200962980W , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200962980N , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200962980H , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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