Basic Information
| Provider Information | |||||||||
| NPI: | 1497060511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOBALIK | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 MATCHETT DR | ||||||||
| Address2: | US HWY 30 W | ||||||||
| City: | PIERCETON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465629073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745942136 | ||||||||
| FaxNumber: | 5745942281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2010 | ||||||||
| LastUpdateDate: | 03/25/2013 | ||||||||
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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 | 133V00000X | 37001977A | IN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000675220 | 01 | IN | ANTHEM | OTHER | 000000675210 | 01 | IN | ANTHEM | OTHER | 000000675021 | 01 | IN | ANTHEM | OTHER |