1730363748 NPI number — ACTIVE PODIATRY PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730363748 NPI number — ACTIVE PODIATRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE PODIATRY 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:
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:
1730363748
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 LAFAYETTE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRAWFORDSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47933-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-362-7200
Provider Business Mailing Address Fax Number:
765-362-4870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 LAFAYETTE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRAWFORDSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47933-1037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-362-7200
Provider Business Practice Location Address Fax Number:
765-362-4870
Provider Enumeration Date:
12/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHAE
Authorized Official First Name:
YONG
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
765-362-7200

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  07000857A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: 07000857A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200178610 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000480680 . This is a "ANTHEM /BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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