Basic Information
| Provider Information | |||||||||
| NPI: | 1902232200 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEKALB HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEKALB HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 623 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467060623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609278105 | ||||||||
| FaxNumber: | 2609278026 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 E 7TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609202894 | ||||||||
| FaxNumber: | 2609202880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2013 | ||||||||
| LastUpdateDate: | 10/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING/COLLECTION MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2609202794 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.