1700184306 NPI number — MRS. ANGIE DIANE BAUER CNP

Table of content: MRS. ANGIE DIANE BAUER CNP (NPI 1700184306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700184306 NPI number — MRS. ANGIE DIANE BAUER CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAUER
Provider First Name:
ANGIE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

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:
1700184306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1306 GLENEAGLES PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENDALE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47025-7517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-584-5928
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 BRIDGEWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47001-1378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-926-0744
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2011

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: 363LF0000X , with the licence number:  COA 12215 NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 3007964 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 71010554A , 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: 7100290260 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0053056 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201222370 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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