Basic Information
Provider Information | |||||||||
NPI: | 1639634637 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMERGENCY PHYSICIAN ASSOCIATES OF INDIANA PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 307 S EVERGREEN AVE | ||||||||
Address2: |   | ||||||||
City: | WOODBURY | ||||||||
State: | NJ | ||||||||
PostalCode: | 080962739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8566864316 | ||||||||
FaxNumber: | 8652913254 | ||||||||
Practice Location | |||||||||
Address1: | 4321 FIR ST | ||||||||
Address2: |   | ||||||||
City: | EAST CHICAGO | ||||||||
State: | IN | ||||||||
PostalCode: | 463123049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2193921700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/04/2019 | ||||||||
LastUpdateDate: | 02/04/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MURTAUGH | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | VP/TREASURER | ||||||||
AuthorizedOfficialTelephone: | 8566864316 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207P00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.