Basic Information
Provider Information | |||||||||
NPI: | 1295763159 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ASHTON | ||||||||
FirstName: | MICHELE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRAY | ||||||||
OtherFirstName: | MICHELE | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6301 UNIVERSITY COMMONS | ||||||||
Address2: | SUITE 230 | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466351571 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742512100 | ||||||||
FaxNumber: | 5742512151 | ||||||||
Practice Location | |||||||||
Address1: | 6301 UNIVERSITY COMMONS | ||||||||
Address2: | SUITE 310 | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466351571 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742321471 | ||||||||
FaxNumber: | 5742398511 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301085065 | MI | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 01066324A | IN | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 000000610078 | 01 | IN | ANTHEM BCBS | OTHER | 07-30407 | 01 | MI | PHP | OTHER | 3286538 | 01 | MI | CIGNA | OTHER | BG9136664 | 01 | MI | DEA | OTHER | 200932860 | 05 | IN |   | MEDICAID |