Provider Demographics
NPI:1497060511
Name:BOBALIK, AMY M (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:BOBALIK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:5 MATCHETT DR
Practice Address - Street 2:US HWY 30 W
Practice Address - City:PIERCETON
Practice Address - State:IN
Practice Address - Zip Code:46562-9073
Practice Address - Country:US
Practice Address - Phone:574-594-2136
Practice Address - Fax:574-594-2281
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001977A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000675220OtherANTHEM
IN000000675210OtherANTHEM
IN000000675021OtherANTHEM
INM400025629Medicare PIN
INM400025630Medicare PIN
INM400025628Medicare PIN
IN000000675021OtherANTHEM