Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RH0002X | Hospice and Palliative Medicine | 01069197A | IN |
NPI | 1376758524 |
---|---|
Provider Name | Jeffrey Alan Dedelow |
First Address | Indianapolis, IN 46219-4959 |
Second Address | Bloomington, IN 47403-2316 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2007 |
Last Update Date | 09/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0090190 | (05) | OH |
04377066 | (05) | MS |
1049913 | (05) | LA |
201015030 | (05) | IN |
5186380 | (05) | MI |
P01119545 | RAILROAD MEDICARE (01) | IN |