Basic Information
Provider Information | |||||||||
NPI: | 1578748554 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITY HEALTHCARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOOVER FOOT CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4699 | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479034699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654492732 | ||||||||
FaxNumber: | 7654465317 | ||||||||
Practice Location | |||||||||
Address1: | 2020 UNION ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479043432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654477644 | ||||||||
FaxNumber: | 7654489009 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2008 | ||||||||
LastUpdateDate: | 09/30/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER | ||||||||
AuthorizedOfficialFirstName: | MARTHA | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING | ||||||||
AuthorizedOfficialTelephone: | 7654465417 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 07000331A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 200898940A | 05 | IN |   | MEDICAID |