Basic Information
| Provider Information | |||||||||
| NPI: | 1720090467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGITRACE CARE SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE PL | ||||||||
| Address2: | SUITE 5B | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019603840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
| FaxNumber: | 9785359757 | ||||||||
| Practice Location | |||||||||
| Address1: | 521 E 86TH AVE | ||||||||
| Address2: | SUITE Z | ||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127690777 | ||||||||
| FaxNumber: | 2197550608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 10/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | IBERGER | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP CFO | ||||||||
| AuthorizedOfficialTelephone: | 9785367400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 01619296 | 01 | IL | FEDERAL BCIL | OTHER | 8011510 | 01 | IL | CIGNA | OTHER |