Provider Demographics
NPI: | 1467461152 |
---|---|
Name: | ZIMMERER, JOHN B (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JOHN |
Middle Name: | B |
Last Name: | ZIMMERER |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1101 MICHIGAN AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | LOGANSPORT |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46947-1528 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 574-753-7541 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1101 MICHIGAN AVE |
Practice Address - Street 2: | |
Practice Address - City: | LOGANSPORT |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46947-1528 |
Practice Address - Country: | US |
Practice Address - Phone: | 574-753-7541 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-05 |
Last Update Date: | 2013-01-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 01041629 | 207L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 000000506214 | Other | BLUE CROSS - ANTHEM |
IN | P00448127 | Other | RAIL ROAD MEDICARE |
IN | 200111250 | Medicaid | |
IN | 200111250 | Medicaid | |
IN | 940670OOOO | Medicare PIN | |
IN | 000000506214 | Other | BLUE CROSS - ANTHEM |
IN | 940900YYY | Medicare PIN |