1689679474 NPI number — JEFFREY D HEADDY RPT

Table of content: JEFFREY D HEADDY RPT (NPI 1689679474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689679474 NPI number — JEFFREY D HEADDY RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEADDY
Provider First Name:
JEFFREY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPT
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:
1689679474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
512 TIMBER RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPENCER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47460-5981
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
639 S WALKER ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47403-2124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-455-1064
Provider Business Practice Location Address Fax Number:
317-455-1204
Provider Enumeration Date:
06/17/2005

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: 225100000X , with the licence number:  05004322A , 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: 200488270 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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