1811092059 NPI number — SURGICAL CONSULTANTS OF NORTHWEST INDIANA ,P.C.

Table of content: (NPI 1811092059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811092059 NPI number — SURGICAL CONSULTANTS OF NORTHWEST INDIANA ,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGICAL CONSULTANTS OF NORTHWEST INDIANA ,P.C.
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:
1811092059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 597
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHERERVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46375-0597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-736-6850
Provider Business Mailing Address Fax Number:
219-736-6855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5521 W LINCOLN HWY
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307-1097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-736-6850
Provider Business Practice Location Address Fax Number:
219-736-6855
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLEZA
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ARNOLD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-736-6850

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  01052161A , 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: 200348360 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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