1922104660 NPI number — BALOG BREMEN VISION CENTER P C

Table of content: (NPI 1922104660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922104660 NPI number — BALOG BREMEN VISION CENTER P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALOG BREMEN VISION CENTER 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:
1922104660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1425 W PLYMOUTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREMEN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46506-1951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-546-3820
Provider Business Mailing Address Fax Number:
574-546-3810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 W PLYMOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREMEN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46506-1951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-546-3820
Provider Business Practice Location Address Fax Number:
574-546-3810
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BALOG
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
574-546-3820

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  18001983A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 18001983A , 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: DA1502 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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