Healthcare Provider Details

I. General information

NPI: 1043271356
Provider Name (Legal Business Name): GARY ALLEN BABCOKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 DICKINSON RD SUITE A
CHESTERTON IN
46304-3387
US

IV. Provider business mailing address

26700 BROOKPARK ROAD EXT SUITE 1
NORTH OLMSTED OH
44070-3124
US

V. Phone/Fax

Practice location:
  • Phone: 219-926-2133
  • Fax: 219-926-8765
Mailing address:
  • Phone: 800-611-6912
  • Fax: 440-716-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01019380A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: