1649720301 NPI number — ASSOCIATED SURGEONS AND PHYSICIANS, 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 1649720301 NPI number — ASSOCIATED SURGEONS AND PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSOCIATED SURGEONS AND PHYSICIANS, 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:
1649720301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2518 E DUPONT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-1675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-432-4400
Provider Business Mailing Address Fax Number:
260-969-6833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1316 E 7TH ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46706-2538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-432-7600
Provider Business Practice Location Address Fax Number:
260-436-8498
Provider Enumeration Date:
10/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BRAGER
Authorized Official First Name:
LILA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
260-432-4400

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201338430 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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