1932139839 NPI number — DOROTHY B. LOLLATHIN PA-C

Table of content: DOROTHY B. LOLLATHIN PA-C (NPI 1932139839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932139839 NPI number — DOROTHY B. LOLLATHIN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOLLATHIN
Provider First Name:
DOROTHY
Provider Middle Name:
B.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1932139839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 REID PARKWAY
Provider Second Line Business Mailing Address:
MEDICAL STAFF SERVICE
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47374-1157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-935-8905
Provider Business Mailing Address Fax Number:
765-939-4200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 HIGHLAND RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47374-8810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-935-8905
Provider Business Practice Location Address Fax Number:
765-939-4200
Provider Enumeration Date:
07/04/2006

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: 363A00000X , with the licence number:  50.002298RX , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 10003160A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000181581 . This is a "UNISON MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0498377 . This is a "MOLINA MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00278526 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000175652 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001769308 . This is a "MOUNTAIN STATE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0075679 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1068920 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 293560617 . This is a "TRI CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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