1972859452 NPI number — COURTNEY B. CORTEZ

Table of content: COURTNEY B. CORTEZ (NPI 1972859452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972859452 NPI number — COURTNEY B. CORTEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORTEZ
Provider First Name:
COURTNEY
Provider Middle Name:
B.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OSTACHUK
Provider Other First Name:
COURTNEY
Provider Other Middle Name:
B.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972859452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12400 N MERIDIAN STE 100
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-559-3320
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12400 N MERIDIAN STE 100
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-559-3320
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2012

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: 363LW0102X , with the licence number:  71004263A , 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: COR1-0437-0895 . This is a "NATIONAL CERTIFICATION CORPORATION - WHNP - BC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 71004263A . This is a "APN LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P01456971 . This is a "MEDICARE RR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201151310 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28162939A . This is a "RN LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P01456971 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 71004263A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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