Provider Demographics
NPI:1134329477
Name:YESSENOW CENTRE, P.C.
Entity Type:Organization
Organization Name:YESSENOW CENTRE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VALORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-836-8136
Mailing Address - Street 1:9250 COLUMBIA AVE
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3538
Mailing Address - Country:US
Mailing Address - Phone:219-836-8136
Mailing Address - Fax:219-836-8135
Practice Address - Street 1:9250 COLUMBIA AVE
Practice Address - Street 2:SUITE A-2
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3538
Practice Address - Country:US
Practice Address - Phone:219-836-8136
Practice Address - Fax:219-836-8135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039206A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN942359OtherUNITED HEALTHCARE NO.
IN88688OtherANTHEM PROVIDER NO.
IN1859137007OtherCIGNA PROVIDER NO.
IN4411395OtherAETNA PROVIDER NO.
IN911-08053OtherBC/BS OF IL PROVIDER NO.
IN1859137007OtherCIGNA PROVIDER NO.
INE82933Medicare UPIN