1578868220 NPI number — INDIANA PHYSICIAN MANAGEMENT-CLAY, LLC

Table of content: (NPI 1578868220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578868220 NPI number — INDIANA PHYSICIAN MANAGEMENT-CLAY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA PHYSICIAN MANAGEMENT-CLAY, 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:
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:
1578868220
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3946 SOLUTIONS CTR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-3009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-802-3113
Provider Business Mailing Address Fax Number:
317-870-0499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1206 E NATIONAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAZIL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47834-2718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-802-3113
Provider Business Practice Location Address Fax Number:
317-870-0499
Provider Enumeration Date:
01/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BICK
Authorized Official First Name:
STEWART
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-338-5053

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201012070 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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