1760947329 NPI number — ELLEN MARGARET KRESCA PA-C

Table of content: ELLEN MARGARET KRESCA PA-C (NPI 1760947329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760947329 NPI number — ELLEN MARGARET KRESCA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRESCA
Provider First Name:
ELLEN
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RANDALL
Provider Other First Name:
ELLEN
Provider Other Middle Name:
MARGARET
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760947329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
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:
46219-4959
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:
705 RILEY HOSPITAL DR STE 2514
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-948-0345
Provider Business Practice Location Address Fax Number:
317-948-0939
Provider Enumeration Date:
02/07/2019

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: 363AS0400X , with the licence number:  10002625A , 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: 300025053 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 074790058 . This is a "MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 300018945 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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