1750463543 NPI number — LAFAYETTE CANCER CARE PC

Table of content: (NPI 1750463543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750463543 NPI number — LAFAYETTE CANCER CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAFAYETTE CANCER CARE 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:
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:
1750463543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1345 UNITY PL
Provider Second Line Business Mailing Address:
STE 135
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47905-5760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1345 UNITY PL
Provider Second Line Business Practice Location Address:
STE 135
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905-5760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-446-5050
Provider Business Practice Location Address Fax Number:
765-446-5119
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMIN
Authorized Official Telephone Number:
765-446-5050

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  01045452A , 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: 1560223 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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