Basic Information
| Provider Information | |||||||||
| NPI: | 1912666744 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RACC MEDICAL ASSOCIATES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SUMMIT PAIN MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | HUNTERTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467480670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607483650 | ||||||||
| FaxNumber: | 2607483651 | ||||||||
| Practice Location | |||||||||
| Address1: | 2124 BIOMET DRIVE | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465827858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607483650 | ||||||||
| FaxNumber: | 2607483651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2021 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROTH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2607483650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 300038645 | 05 | IN | MEDICAID |