Basic Information
| Provider Information | |||||||||
| NPI: | 1104042597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANNIS | ||||||||
| FirstName: | CHRISTY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAUCK | ||||||||
| OtherFirstName: | CHRISTY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5215 HOLY CROSS PKWY | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743355000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5215 HOLY CROSS PKWY | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743355000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 12/16/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036.125342 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 57.012518 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 01069919 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000724321 | 01 | IN | ANTHEM | OTHER | 201028090 | 05 | IN | MEDICAID | P00967673 | 01 | IN | RR MEDICARE | OTHER |