Basic Information
Provider Information | |||||||||
NPI: | 1356814982 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCPIKE | ||||||||
FirstName: | TRAVIS | ||||||||
MiddleName: | RANDALL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1100 SOUTHFIELD DR STE 1370 | ||||||||
Address2: |   | ||||||||
City: | PLAINFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 461684300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178375570 | ||||||||
FaxNumber: | 3178375580 | ||||||||
Practice Location | |||||||||
Address1: | 1152 E US HIGHWAY 36 | ||||||||
Address2: |   | ||||||||
City: | BAINBRIDGE | ||||||||
State: | IN | ||||||||
PostalCode: | 461059604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7655221889 | ||||||||
FaxNumber: | 7655223583 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/07/2019 | ||||||||
LastUpdateDate: | 03/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28213528A | IN | Y |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.