Provider Demographics
NPI:1013912138
Name:UMBACH, ALBERT JOHN III (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:JOHN
Last Name:UMBACH
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:BLDG D SUITE 100
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-688-1770
Practice Address - Fax:270-688-1781
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000261A363A00000X, 363AS0400X
KYPA415363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000074048OtherANTHEM BLUE CROSS
KY970007856Medicare PIN
000000074048OtherANTHEM BLUE CROSS
KY0649903Medicare PIN
S60356Medicare UPIN
IN202280EMedicare PIN