1508192147 NPI number — PHILLIP G. KOULTOURIDES, O.D. P.C.

Table of content: DR. ROBERT RYAN VERCHOTA D.C. (NPI 1568691095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508192147 NPI number — PHILLIP G. KOULTOURIDES, O.D. P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILLIP G. KOULTOURIDES, O.D. P.C.
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:
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:
1508192147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9140 DRAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOHN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46373-9066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-365-8069
Provider Business Mailing Address Fax Number:
219-465-2785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 MORTHLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46383-8329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-465-2788
Provider Business Practice Location Address Fax Number:
219-465-2785
Provider Enumeration Date:
11/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KOULTOURIDES
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-365-8069

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18003080 , 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)





Copyright © 2007-2025 www.npivalidator.com