1639109945 NPI number — EMERGENCY MEDICINE PROFESSIONALS OF INDIANA LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639109945 NPI number — EMERGENCY MEDICINE PROFESSIONALS OF INDIANA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERGENCY MEDICINE PROFESSIONALS OF INDIANA 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:
1639109945
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1204
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:
46206-1204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-802-3160
Provider Business Mailing Address Fax Number:
317-870-0499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4011 SO MONROE MEDICAL PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47403-9765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-824-5700
Provider Business Practice Location Address Fax Number:
812-825-0766
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANSHIP
Authorized Official First Name:
MARK
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-870-0480

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: 200828620A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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