Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 01063510A | IN |
Y | 111NI0900X | Internist | 01063510A | IN |
N | 207R00000X | Internist | 4301081193 | MI |
N | 111NI0900X | Internist | 4301081193 | MI |
N | 207RH0002X | Hospice and Palliative Medicine | 01063510A | IN |
NPI | 1316961956 |
---|---|
Provider Name | Sternlate Tshililiwa |
First Address | Indianapolis, IN 46219-4959 |
Second Address | Fort Wayne, IN 46845-1701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2006 |
Last Update Date | 01/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1316961956 | (05) | MI |
1417961137 | BCBSM - BMH (01) | MI |
201021130 | (05) | IN |