Basic Information
| Provider Information | |||||||||
| NPI: | 1497709950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MBWOUDE, INC. | ||||||||
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| OtherOrganizationName: | APT PLUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 JOLIET ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198643300 | ||||||||
| FaxNumber: | 2198642569 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 JOLIET ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198643300 | ||||||||
| FaxNumber: | 2198642569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WATERFIELD | ||||||||
| AuthorizedOfficialFirstName: | JEANNE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OFFICE ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 2198643300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 164465 | 01 | IN | INDIANA DEPT OF HEALTH | OTHER | 000000324507 | 01 | IN | ANTHEM BCBS | OTHER | 0586236 | 01 | IN | CIGNA | OTHER | 90001153 | 01 | IN | BC OF ILLINOIS | OTHER | 5195522 | 01 | IN | AETNA | OTHER |