1093443889 NPI number — MADELINE DIANE THOMPSON KLUGMANN

Table of content: MADELINE DIANE THOMPSON KLUGMANN (NPI 1093443889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093443889 NPI number — MADELINE DIANE THOMPSON KLUGMANN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON KLUGMANN
Provider First Name:
MADELINE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093443889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 DEPAUW BLVD STE 3070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-6135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-324-0885
Provider Business Mailing Address Fax Number:
317-520-8200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8027 COOPER CREEK BLVD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34201-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-477-2080
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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