Basic Information
Provider Information | |||||||||
NPI: | 1417956384 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMERGENCY PHYSICIANS OF DELAWARE COUNTY, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3620 N EVERBROOK LN | ||||||||
Address2: | SUITE F | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473045200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2609691950 | ||||||||
FaxNumber: | 7657411424 | ||||||||
Practice Location | |||||||||
Address1: | 2401 W UNIVERSITY AVE | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473033428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2609691950 | ||||||||
FaxNumber: | 7657411424 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2005 | ||||||||
LastUpdateDate: | 12/10/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOX | ||||||||
AuthorizedOfficialFirstName: | ROBIN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2609691950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 50004368A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100104590A | 05 | IN |   | MEDICAID | 000000101121 | 01 | IN | BLUE CROSS/BLUE SHIELD | OTHER | 128786100 | 01 | IN | DEPARTMENT OF LABOR | OTHER |