1598831844 NPI number — MRS. KELLY BETH PUGLIESE MSPT ATC

Table of content: MRS. KELLY BETH PUGLIESE MSPT ATC (NPI 1598831844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598831844 NPI number — MRS. KELLY BETH PUGLIESE MSPT ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUGLIESE
Provider First Name:
KELLY
Provider Middle Name:
BETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT ATC
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:
1598831844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4850 W CENTURY PLAZA RD
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:
46254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-216-2828
Provider Business Mailing Address Fax Number:
317-216-2839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6349 SOUTH EAST STREET US31
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-780-2005
Provider Business Practice Location Address Fax Number:
317-780-2006
Provider Enumeration Date:
11/28/2006

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: 225100000X , with the licence number:  05003428A , 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)





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