Basic Information
Provider Information | |||||||||
NPI: | 1235231689 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AUBURN FAMILY MEDICINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 09/05/2006 | ||||||||
LastUpdateDate: | 08/11/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURTON | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | LANCE | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 2609251255 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000000105226 | 01 | IN | ANTHEM | OTHER | 200237200 | 05 | IN |   | MEDICAID |