1982678470 NPI number — DR. ANTWAN M MARDINI MD

Table of content: DR. ANTWAN M MARDINI MD (NPI 1982678470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982678470 NPI number — DR. ANTWAN M MARDINI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARDINI
Provider First Name:
ANTWAN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1982678470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2723 S 7TH ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
TERRE HAUTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47802-3558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-238-1730
Provider Business Mailing Address Fax Number:
812-242-1565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1530 N 7TH ST
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47807-1057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-232-9663
Provider Business Practice Location Address Fax Number:
812-232-2980
Provider Enumeration Date:
02/14/2006

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: 207R00000X , with the licence number:  01048595 , 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: P00059999 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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