1962837393 NPI number — OURHEALTH PROFESSIONAL PHYSICIAN GROUP, LLC

Table of content: (NPI 1962837393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962837393 NPI number — OURHEALTH PROFESSIONAL PHYSICIAN GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OURHEALTH PROFESSIONAL PHYSICIAN GROUP, 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:
6
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:
1962837393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 W MARKET ST STE 2900
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46204-2964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-434-3255
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 RIVERFORK DR
Provider Second Line Business Practice Location Address:
C/O BENDIX HEALTH CENTER
Provider Business Practice Location Address City Name:
HUNTINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46750-9004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-200-1310
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WELLS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
317-522-0823

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 71004183A , 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)





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