Basic Information
| Provider Information | |||||||||
| NPI: | 1184622367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAGE | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 E 7TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609251255 | ||||||||
| FaxNumber: | 2609251256 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 E 7TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609251255 | ||||||||
| FaxNumber: | 2609251256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 09/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01047310 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01047310 | 01 | IN | STATE LICENSE | OTHER | 15D0962889 | 01 | IN | CLIA | OTHER | 5988752 | 01 | IN | AETNA | OTHER | 200218780A | 05 | IN | MEDICAID | BP5488615 | 01 | IN | DEA | OTHER |