1790966810 NPI number — MARCUS WIGUTOW, M.D., INC.

Table of content: (NPI 1790966810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790966810 NPI number — MARCUS WIGUTOW, M.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARCUS WIGUTOW, M.D., INC.
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:
1790966810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9120 CONNECTICUT DR.
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
MERRILLVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46410-7172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-759-5900
Provider Business Mailing Address Fax Number:
219-769-5987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9120 CONNECTICUT DR
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410-7172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-769-5900
Provider Business Practice Location Address Fax Number:
219-769-5987
Provider Enumeration Date:
11/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WIGUTOW
Authorized Official First Name:
MARCUS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-769-5900

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  01022387B , 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: 1320159050 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 91106545 . This is a "BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 000000095335 . This is a "BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 03166600 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 137824 . This is a "COMPSYCH" identifier . This identifiers is of the category "OTHER".




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