Basic Information
| Provider Information | |||||||||
| NPI: | 1336411941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERRIGAN | ||||||||
| FirstName: | MARGO | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | CST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5545 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479035545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2600 GREENBUSH ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479042477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | 7654487625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2012 | ||||||||
| LastUpdateDate: | 05/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | CERT# 128568 | IN | Y |
ID Information
| ID | Type | State | Issuer | Description | 000000750384 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER |