Provider Demographics
NPI:1790940476
Name:PAOLO C GIACOMINI, M.D. PC
Entity Type:Organization
Organization Name:PAOLO C GIACOMINI, M.D. PC
Other - Org Name:ASH STREET CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAOLO C. GIACOMINI
Authorized Official - Middle Name:C
Authorized Official - Last Name:GIACOMINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-563-8875
Mailing Address - Street 1:400 ASH ST
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1954
Mailing Address - Country:US
Mailing Address - Phone:260-563-8875
Mailing Address - Fax:
Practice Address - Street 1:400 ASH ST
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1954
Practice Address - Country:US
Practice Address - Phone:260-563-8875
Practice Address - Fax:260-569-9803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038356208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200042050AMedicaid
INC64133Medicare UPIN