Basic Information
| Provider Information | |||||||||
| NPI: | 1689653982 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITIZENS HEALTH CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CITIZENS HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 N COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179246351 | ||||||||
| FaxNumber: | 3179273634 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 N COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179246351 | ||||||||
| FaxNumber: | 3179273634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 12/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | GIBSON | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3173960279 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 50000856A | IN | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 3336C0002X | 60003640A | IN | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 100196020B | 05 | IN | MEDICAID | 1524758 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 100196020A | 05 | IN | MEDICAID | 100297090A | 05 | IN | MEDICAID |