Basic Information
| Provider Information | |||||||||
| NPI: | 1518968544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NETLUCH | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | MYRON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 S MAIN ST | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463078481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197576310 | ||||||||
| FaxNumber: | 2197576312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 S MAIN ST | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463078481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197576310 | ||||||||
| FaxNumber: | 2197576312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2005 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01038329A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100387940 | 05 | IN | MEDICAID |