1700824653 NPI number — DR. KATHLEEN A FLANNAGAN MD

Table of content: DR. KATHLEEN A FLANNAGAN MD (NPI 1700824653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700824653 NPI number — DR. KATHLEEN A FLANNAGAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLANNAGAN
Provider First Name:
KATHLEEN
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHWIERLING
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700824653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2005 ST. CHARLES STREET
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-634-6600
Provider Business Mailing Address Fax Number:
812-634-6621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2005 ST. CHARLES STREET
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-634-6600
Provider Business Practice Location Address Fax Number:
812-634-6621
Provider Enumeration Date:
06/03/2006

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: 207W00000X , with the licence number:  35-085231 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 01063124A , 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: 2633127 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200520030 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64110737 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000363168 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 31.1473421 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".




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