Basic Information
| Provider Information | |||||||||
| NPI: | 1215938592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANNINGSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1314 E 7TH ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609278105 | ||||||||
| FaxNumber: | 2609278026 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 E 7TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609255511 | ||||||||
| FaxNumber: | 2609258353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208D00000X | 01039769A | IN | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 000000081119 | 01 | IN | ANTHEM | OTHER | 1035 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER |