1871765057 NPI number — DR. JASON MICHAEL PETRUNGARO M.D.

Table of content: DR. JASON MICHAEL PETRUNGARO M.D. (NPI 1871765057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871765057 NPI number — DR. JASON MICHAEL PETRUNGARO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRUNGARO
Provider First Name:
JASON
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1871765057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 MACARTHUR BLVD
Provider Second Line Business Mailing Address:
SUITE 21
Provider Business Mailing Address City Name:
MUNSTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46321-2917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-836-1163
Provider Business Mailing Address Fax Number:
844-270-6677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MACARTHUR BLVD
Provider Second Line Business Practice Location Address:
SUITE 21
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-2917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-836-1163
Provider Business Practice Location Address Fax Number:
844-270-6677
Provider Enumeration Date:
03/28/2008

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: 2086S0122X , with the licence number:  N9993 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X , with the licence number: 01074460A , 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: 8DT481 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: MEDICARE . This is a "IN2244001" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P01602561 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 0914915 . This is a "BCBS IN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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