Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 01043612A | IN |
N | 207QS0010X | Family Doctor - Sports Medicine | 01043612A | IN |
NPI | 1124001094 |
---|---|
Provider Name | Stephen Henry Berghofer |
First Address | Indianapolis, IN 46290-1024 |
Second Address | Alexandria, IN 46001-2067 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/11/2005 |
Last Update Date | 03/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200062200 | (05) | IN |
DC3600 | RAILROAD GROUP (01) | IN |
G16058 | (02) | |
P00616368 | RAILROAD INDIVIDUAL (01) | IN |