1942303870 NPI number — AMERICAN MEDICAL ASSOCIATES LLC

Table of content: (NPI 1942303870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942303870 NPI number — AMERICAN MEDICAL ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERICAN MEDICAL ASSOCIATES LLC
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:
1942303870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
539 SAINT ANDREWS DR
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:
46375-2951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-459-9661
Provider Business Mailing Address Fax Number:
219-937-2981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9250 COLUMBIA AVE STE 1F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-3530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-937-9653
Provider Business Practice Location Address Fax Number:
219-937-2981
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
RUDYARD
Authorized Official Middle Name:
U
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-937-9653

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15D1025134 . This is a "CLIA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200145800 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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