1740458207 NPI number — MCH PROFESSIONAL CARE

Table of content: (NPI 1740458207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740458207 NPI number — MCH PROFESSIONAL CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCH PROFESSIONAL CARE
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:
1740458207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 643
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46206-0643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-640-2401
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-5001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-640-2401
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CONWAY
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
432-640-2401

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 197485901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0065JH . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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