Provider Demographics
NPI:1619010626
Name:APPLEGARTH DERMATOLOGY PC
Entity Type:Organization
Organization Name:APPLEGARTH DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:APPLEGARTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-548-0360
Mailing Address - Street 1:1510 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5150
Mailing Address - Country:US
Mailing Address - Phone:219-324-4947
Mailing Address - Fax:
Practice Address - Street 1:1861 S STURDY RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-548-0360
Practice Address - Fax:219-548-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039449A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDA2999Medicare UPIN
IN218420Medicare ID - Type Unspecified