1972839777 NPI number — MAGNOLIA HEALTH SYSTEMS XI

Table of content: (NPI 1972839777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972839777 NPI number — MAGNOLIA HEALTH SYSTEMS XI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA HEALTH SYSTEMS XI
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:
AZALEA HILLS
Provider Other Organization Name Type Code:
3
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:
1972839777
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9455 DELEGATES ROW
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:
46240-3805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-818-1240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3700 LAFAYETTE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOYDS KNOBS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47119-9788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-923-4888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
REED
Authorized Official First Name:
STUART
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
317-818-1240

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09-012161-1 . This is a "STATE LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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