Basic Information
| Provider Information | |||||||||
| NPI: | 1255592309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MURRAY | ||||||||
| FirstName: | LOREN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HURST | ||||||||
| OtherFirstName: | LOREN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 775383 SANDREST FAMILY MEDICINE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606774427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123753000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3203 MIDDLE DR | ||||||||
| Address2: | SANDREST FAMILY MEDICINE | ||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123732700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2008 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01067918A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | M400051986 | 01 | IN | MEDICARE- OTHER | OTHER | 000000724790 | 01 | IN | ANTHEM | OTHER | 000000984085 | 01 | IN | ANTHEM PIN | OTHER | 01067918A | 01 | IN | INDIANA LICENSE | OTHER | 201029100 | 05 | IN | MEDICAID |