1679741235 NPI number — MICHAEL L RUPLEY PHD PC

Table of content: (NPI 1679741235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679741235 NPI number — MICHAEL L RUPLEY PHD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL L RUPLEY PHD 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:
6
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:
1679741235
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
323 WEST 4TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISHAWAKA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46544-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-256-2258
Provider Business Mailing Address Fax Number:
574-256-2266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
323 WEST 4TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46544-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-256-2258
Provider Business Practice Location Address Fax Number:
574-256-2266
Provider Enumeration Date:
02/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RUPLEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
574-256-2258

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  20010350 , 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: 000000214616 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100089740 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100089740A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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