1649232190 NPI number — JOANNE FODEMSKI

Table of content: (NPI 1649232190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649232190 NPI number — JOANNE FODEMSKI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOANNE FODEMSKI
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:
JARAN MEDICAL SERVICES
Provider Other Organization Name Type Code:
3
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:
1649232190
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1286
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROWN POINT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46308-1286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-226-0424
Provider Business Mailing Address Fax Number:
219-226-0426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
730 WIRTZ RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-226-0424
Provider Business Practice Location Address Fax Number:
219-226-0426
Provider Enumeration Date:
04/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FODEMSKI
Authorized Official First Name:
JOANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-226-0424

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200466780A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000220428 . This is a "BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 0582874 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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