1689872152 NPI number — SPINE & MUSCULOSKELETAL CENTER PC

Table of content: (NPI 1689872152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689872152 NPI number — SPINE & MUSCULOSKELETAL CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE & MUSCULOSKELETAL CENTER 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:
1689872152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9430 WICKER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOHN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46373-9768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-558-8068
Provider Business Mailing Address Fax Number:
219-558-8149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 E COLUMBUS DRIVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EAST CHICAGO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46312-3078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-397-8648
Provider Business Practice Location Address Fax Number:
219-397-8653
Provider Enumeration Date:
07/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SPOTT
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-397-8648

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  2001917 , 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: 200184170D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7538064 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00222849 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036105846 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90001235 . This is a "BCBS IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 000000373304 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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