Basic Information
Provider Information
NPI: 1720026826
EntityType: 2
ReplacementNPI:  
OrganizationName: HOOSIER EMERGENCY PHYSICIANS LLC
LastName:  
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Mailing Information
Address1: PO BOX 13621
Address2:  
City: PHILADELPHIA
State: PA
PostalCode: 191013621
CountryCode: US
TelephoneNumber: 4694012386
FaxNumber:  
Practice Location
Address1: 2200 N SECTION ST
Address2:  
City: SULLIVAN
State: IN
PostalCode: 478827523
CountryCode: US
TelephoneNumber: 8122684311
FaxNumber: 8122682650
Other Information
ProviderEnumerationDate: 06/02/2006
LastUpdateDate: 01/22/2018
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: BEHM
AuthorizedOfficialFirstName: TENNA
AuthorizedOfficialMiddleName: K
AuthorizedOfficialTitleorPosition: OFFICER
AuthorizedOfficialTelephone: 4694012386
IsSoleProprietor:  
IsOrganizationSubpart: N
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207P00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansEmergency Medicine 

ID Information
IDTypeStateIssuerDescription
00000036147401INBLUE SHIELDOTHER
200524970A05IN MEDICAID


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