Basic Information
| Provider Information | |||||||||
| NPI: | 1184680159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEJONG | ||||||||
| FirstName: | KURTIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5215 HOLY CROSS PKWY | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743355000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5215 HOLY CROSS PKWY | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743355000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 12/16/2011 | ||||||||
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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 | 207PE0004X | 01039621 | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 01039621 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930102831 | 01 | IN | RAIL ROAD MEDICARE | OTHER | 104943838 | 05 | MI | MEDICAID | 000000190295 | 01 | IN | ANTHEM | OTHER | 200022520 | 05 | IN | MEDICAID |