Basic Information
| Provider Information | |||||||||
| NPI: | 1629065867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UDANI | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463110800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198642107 | ||||||||
| FaxNumber: | 2198642649 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 US HIGHWAY 41 | ||||||||
| Address2: | SUITE #1 | ||||||||
| City: | SCHERERVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463751277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198643950 | ||||||||
| FaxNumber: | 2198643952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 03/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02001229A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0090000854 | 01 | IL | BCBS GROUP NUMBER | OTHER | 100147500 | 05 | IN | MEDICAID |