Provider Demographics
NPI:1235204421
Name:STREETER MEDICAL-SURGICAL, P.C.
Entity Type:Organization
Organization Name:STREETER MEDICAL-SURGICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-769-6221
Mailing Address - Street 1:119 E 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7184
Mailing Address - Country:US
Mailing Address - Phone:219-769-6221
Mailing Address - Fax:
Practice Address - Street 1:119 E 89TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7184
Practice Address - Country:US
Practice Address - Phone:219-769-6221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000320B208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000084728OtherINDIANA ANTHEM
IN100166240Medicaid
IL9000235OtherILLINOIS BLUE CROSS
IN100166240Medicaid
IN791021241Medicare ID - Type UnspecifiedRAILROAD MEDICARE