Provider Demographics
NPI:1568439180
Name:LUDWIG, JEROME (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:LUDWIG
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 1:4548 SOLUTIONS CTR # 774548
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-4005
Mailing Address - Country:US
Mailing Address - Phone:260-969-1950
Mailing Address - Fax:260-918-2137
Practice Address - Street 1:2512 E DUPONT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1675
Practice Address - Country:US
Practice Address - Phone:260-436-6667
Practice Address - Fax:260-469-7437
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023713A208800000X
OH35038124L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000087513OtherBLUE CROSS BLUE SHIELD
OH0288817Medicaid
IN100401240Medicaid
IN340010558OtherRAILROAD MEDICARE
OH0570855Medicare PIN
IN136140DDMedicare PIN
INC02964Medicare UPIN
IN136140FMedicare PIN