1700966355 NPI number — DR. MARY BETH BETH WOEHRLE OD

Table of content: DR. MARY BETH BETH WOEHRLE OD (NPI 1700966355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700966355 NPI number — DR. MARY BETH BETH WOEHRLE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOEHRLE
Provider First Name:
MARY BETH
Provider Middle Name:
BETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1700966355
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9795 CROSSPOINT BLVD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46256-3354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-254-6480
Provider Business Mailing Address Fax Number:
317-259-8609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
980 S AVERITT ROAD
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46143-9450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-881-4143
Provider Business Practice Location Address Fax Number:
317-259-8609
Provider Enumeration Date:
10/17/2006

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: 152WV0400X , with the licence number:  8002492B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 18002492A , 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: 200227780 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 351850049102 . This is a "CARESOURCE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000299181 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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