1639164999 NPI number — CREEKSIDE OBGYN PC

Table of content: (NPI 1639164999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639164999 NPI number — CREEKSIDE OBGYN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREEKSIDE OBGYN PC
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:
1639164999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2505 N LEBANON ST
Provider Second Line Business Mailing Address:
STE 208
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46052-8612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-485-8444
Provider Business Mailing Address Fax Number:
765-483-7365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2505 N LEBANON ST
Provider Second Line Business Practice Location Address:
STE 208
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46052-8612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-485-8444
Provider Business Practice Location Address Fax Number:
765-483-7365
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
765-483-7361

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  50004241A , 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: 200293550 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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