Healthcare Provider Details

I. General information

NPI: 1356848386
Provider Name (Legal Business Name): SAMANTHA J FLECKENSTEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA MAYHEW

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 W GOELLER BLVD STE A
COLUMBUS IN
47201-8309
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-375-3330
  • Fax: 812-375-3329
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01086237
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: