1619310042 NPI number — MERIDIAN PAIN GROUP

Table of content: (NPI 1619310042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619310042 NPI number — MERIDIAN PAIN GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERIDIAN PAIN GROUP
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:
1619310042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
69 E GARNER RD
Provider Second Line Business Mailing Address:
300
Provider Business Mailing Address City Name:
BROWNSBURG
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46112-7698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-550-3999
Provider Business Mailing Address Fax Number:
888-588-4403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
69 E GARNER RD
Provider Second Line Business Practice Location Address:
300
Provider Business Practice Location Address City Name:
BROWNSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46112-7698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-550-3999
Provider Business Practice Location Address Fax Number:
888-588-4403
Provider Enumeration Date:
04/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
GARY
Authorized Official Middle Name:
HOWARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-550-3999

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  01027589A , 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: 50005219A . This is a "MEDLICAL CORPORATION" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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