1568756930 NPI number — MISS ROSE MAE BROUGHTON MD

Table of content: MISS ROSE MAE BROUGHTON MD (NPI 1568756930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568756930 NPI number — MISS ROSE MAE BROUGHTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUGHTON
Provider First Name:
ROSE MAE
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TANTOCO
Provider Other First Name:
ROSE MAE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1568756930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
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:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
651 ARMORY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELPHI
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46923-1910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-564-2777
Provider Business Practice Location Address Fax Number:
765-564-6580
Provider Enumeration Date:
06/02/2011

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: 207R00000X , with the licence number:  01069257A , 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: 000000898754 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201039510 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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