Provider Demographics
NPI:1134163595
Name:THADDEUS F. RADZIWIECKI, D.P.M., P.C.
Entity type:Organization
Organization Name:THADDEUS F. RADZIWIECKI, D.P.M., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THADDEUS
Authorized Official - Middle Name:F
Authorized Official - Last Name:RADZIWIECKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:219-838-4000
Mailing Address - Street 1:3641 RIDGE RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2080
Mailing Address - Country:US
Mailing Address - Phone:219-838-4000
Mailing Address - Fax:219-838-4387
Practice Address - Street 1:3641 RIDGE RD
Practice Address - Street 2:SUITE 6
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2080
Practice Address - Country:US
Practice Address - Phone:219-838-4000
Practice Address - Fax:219-838-4387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN52000081A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000080130OtherBLUE CROSS & BLUE SHIELD
480026572OtherRAILROAD MEDICARE
IN5622190001OtherMEDICARE DMEPOS
317683484OtherCHAMPUS/CHAMPVA
IN5622190001OtherMEDICARE DMEPOS
T34988Medicare UPIN