1669558300 NPI number — FRANCISCAN HEALTH RENSSELAER, INC.

Table of content: (NPI 1669558300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669558300 NPI number — FRANCISCAN HEALTH RENSSELAER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRANCISCAN HEALTH RENSSELAER, INC.
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:
1669558300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1104 E GRACE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENSSELAER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47978-3211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-866-5141
Provider Business Mailing Address Fax Number:
219-866-3234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1104 E GRACE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENSSELAER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47978-3211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-866-5141
Provider Business Practice Location Address Fax Number:
219-866-3234
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
TERRANCE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
765-502-4440

Provider Taxonomy Codes

  • Taxonomy code: 275N00000X , with the licence number:  05-005072-2 , 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: 80536700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000097884 . This is a "BLUE CROSS ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 909962000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0564195 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0150078 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0175224 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100269660A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: MEDICAID CARESOURCE , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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