1831180306 NPI number — DENNIS FITZPATRICK MD

Table of content: DENNIS FITZPATRICK MD (NPI 1831180306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831180306 NPI number — DENNIS FITZPATRICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZPATRICK
Provider First Name:
DENNIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1831180306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 N NILES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-1924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-1610
Provider Business Mailing Address Fax Number:
574-237-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 ARCADE AVE STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46514-2485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-389-5656
Provider Business Practice Location Address Fax Number:
574-523-7891
Provider Enumeration Date:
11/02/2005

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: 207LC0200X , with the licence number:  46012 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LC0200X , with the licence number: 01064493A , 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: 13580 . This is a "DEAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 34427300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46012 . This is a "TOUCHPOINT" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: WI01K9 . This is a "JOHN DEERE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 200986470 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 236040234 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00058702 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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