Basic Information
| Provider Information | |||||||||
| NPI: | 1235256538 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERIDIAN SERVICES CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COMPREHENSIVE MENTAL HEALTH SERVICS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1528 NW 5TH ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473741844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 10/27/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAFER | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7652881928 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 343900000X | 422-0-CMHC | IN | Y | Transportation Services | Non-emergency Medical Transport (VAN) |
ID Information
| ID | Type | State | Issuer | Description | 200844870B | 05 | IN | MEDICAID | 200844870A | 05 | IN | MEDICAID |