1679768642 NPI number — GOLDEN CARE PODIATRY

Table of content: (NPI 1679768642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679768642 NPI number — GOLDEN CARE PODIATRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN CARE PODIATRY
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:
1679768642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4725 STATESMEN DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-5645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-713-1100
Provider Business Mailing Address Fax Number:
317-713-1100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4725 STATESMEN DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46250-5645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-713-1100
Provider Business Practice Location Address Fax Number:
317-713-1100
Provider Enumeration Date:
09/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KRUEGER
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-713-1111

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100239180 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000344455 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com