1689678955 NPI number — DR. JOHN MIRRO MD

Table of content: DR. JOHN MIRRO MD (NPI 1689678955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689678955 NPI number — DR. JOHN MIRRO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIRRO
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1689678955
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7895 GRAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOBART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46342-6665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-947-1910
Provider Business Mailing Address Fax Number:
219-947-3117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E 87TH AVE STE 420
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410-7335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-758-5008
Provider Business Practice Location Address Fax Number:
219-758-5009
Provider Enumeration Date:
06/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  01024382A , 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: 110044492 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100187310A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000085025 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 9115389 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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