Basic Information
| Provider Information | |||||||||
| NPI: | 1568439180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUDWIG | ||||||||
| FirstName: | JEROME | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4548 SOLUTIONS CTR # 774548 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606774005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609691950 | ||||||||
| FaxNumber: | 2609182137 | ||||||||
| Practice Location | |||||||||
| Address1: | 2512 E DUPONT RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604366667 | ||||||||
| FaxNumber: | 2604697437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 01023713A | IN | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | 35038124L | OH | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 000000087513 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER | 0288817 | 05 | OH | MEDICAID | 100401240 | 05 | IN | MEDICAID | 340010558 | 01 | IN | RAILROAD MEDICARE | OTHER |