Provider Demographics
NPI:1821018250
Name:LAFAYETTE WOMANS HEALTH
Entity Type:Organization
Organization Name:LAFAYETTE WOMANS HEALTH
Other - Org Name:WOMANS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:IDESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-428-5888
Mailing Address - Street 1:3920 ST FRANCIS WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4917
Mailing Address - Country:US
Mailing Address - Phone:765-428-5888
Mailing Address - Fax:765-428-5897
Practice Address - Street 1:3920 ST FRANCIS WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4917
Practice Address - Country:US
Practice Address - Phone:765-428-5888
Practice Address - Fax:765-428-5897
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAFAYETTE WOMANS HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-20
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200303310BMedicaid
234340Medicare PIN