Healthcare Provider Details

I. General information

NPI: 1326071192
Provider Name (Legal Business Name): LAFAYETTE WOMANS HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 ST FRANCIS WAY SUITE 110
LAFAYETTE IN
47905-4917
US

IV. Provider business mailing address

3920 ST FRANCIS WAY SUITE 110
LAFAYETTE IN
47905-4917
US

V. Phone/Fax

Practice location:
  • Phone: 765-428-5800
  • Fax: 765-428-5802
Mailing address:
  • Phone: 765-428-5800
  • Fax: 765-428-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT IDESON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 765-428-5888