Basic Information
Provider Information | |||||||||
NPI: | 1487661500 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FISHER | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | JANE ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOUY-FISHER | ||||||||
OtherFirstName: | SARAH | ||||||||
OtherMiddleName: | JANE ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 520 S 7TH ST | ||||||||
Address2: |   | ||||||||
City: | VINCENNES | ||||||||
State: | IN | ||||||||
PostalCode: | 475911038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128853228 | ||||||||
FaxNumber: | 8128853089 | ||||||||
Practice Location | |||||||||
Address1: | 520 S 7TH ST | ||||||||
Address2: |   | ||||||||
City: | VINCENNES | ||||||||
State: | IN | ||||||||
PostalCode: | 475911038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128853228 | ||||||||
FaxNumber: | 8128853089 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2006 | ||||||||
LastUpdateDate: | 06/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 036.154085 | IL | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 4803229 | 05 | MI |   | MEDICAID | SG008555 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 152230 | 01 | MI | GREAT LAKES HEALTH PLAN | OTHER |