Basic Information
| Provider Information | |||||||||
| NPI: | 1477504181 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERIDIAN HEALTH SERVICES CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MERIDIAN HEALTH SERVICES CORP-RUSHVILLE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 240 N. TILLOTSON AVENUE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410310 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 HARCOURT WAY | ||||||||
| Address2: | |||||||||
| City: | RUSHVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461731165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659323699 | ||||||||
| FaxNumber: | 7659324164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 12/18/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAFER | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
| AuthorizedOfficialTelephone: | 7652881928 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QR1300X | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100216100A | 05 | IN | MEDICAID | 100216100 | 05 | IN | MEDICAID |