Basic Information
Provider Information | |||||||||
NPI: | 1780680942 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PARKVIEW HOSPITAL INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PARKVIEW HOME INFUSION SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5600 | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468955600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2603737008 | ||||||||
FaxNumber: | 2603737059 | ||||||||
Practice Location | |||||||||
Address1: | 1450 PRODUCTION RD STE 100 | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468081167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2603739775 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2005 | ||||||||
LastUpdateDate: | 04/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WICKENS | ||||||||
AuthorizedOfficialFirstName: | JEANNE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VP -- CFO | ||||||||
AuthorizedOfficialTelephone: | 2602669313 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PARKVIEW HOSPITAL INC. | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251F00000X | 60004991A | IN | Y |   | Agencies | Home Infusion |   |
ID Information
ID | Type | State | Issuer | Description | 200209610A | 05 | IN |   | MEDICAID |