Basic Information
Provider Information | |||||||||
NPI: | 1396056016 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHRISTMAN | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JERRELL | ||||||||
OtherFirstName: | MEGAN | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 24 FRANK LLOYD WRIGHT DR | ||||||||
Address2: |   | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481059484 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7347476766 | ||||||||
FaxNumber: | 7342223100 | ||||||||
Practice Location | |||||||||
Address1: | 550 UNIVERSITY BLVD | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462025149 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179448231 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2010 | ||||||||
LastUpdateDate: | 12/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | OS017069 | PA | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 5101021854 | MI | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 02004873A | IN | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 1029211550005 | 05 | PA |   | MEDICAID | 1029211550002 | 05 | PA |   | MEDICAID | 201383800 | 05 | IN |   | MEDICAID | 1029211550001 | 05 | PA |   | MEDICAID | 1029211550003 | 05 | PA |   | MEDICAID | 1029211550004 | 05 | PA |   | MEDICAID |