Basic Information
Provider Information | |||||||||
NPI: | 1356336788 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASSIDY | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3640 NEW VISION DRIVE | ||||||||
Address2: | SUITE A | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468451717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604824440 | ||||||||
FaxNumber: | 2604824442 | ||||||||
Practice Location | |||||||||
Address1: | 2200 RANDALLIA DR | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468054638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2603734000 | ||||||||
FaxNumber: | 2604824442 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2005 | ||||||||
LastUpdateDate: | 05/11/2016 | ||||||||
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 | 207P00000X | 01054605A | IN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 104874614 | 05 | MI |   | MEDICAID | 000000010974 | 01 |   | MPLAN | OTHER | 930113729 | 01 |   | RR MEDICARE | OTHER | 000000214697 | 01 | IN | ANTHEM | OTHER | 047840VVV | 01 |   | MEDICARE WPS/CMS | OTHER | 200364960 | 05 | IN |   | MEDICAID | 2521284 | 05 | OH |   | MEDICAID |