Healthcare Provider Details

I. General information

NPI: 1700888948
Provider Name (Legal Business Name): GARY LYNN ADSIT D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W KEM RD
MARION IN
46952-1548
US

IV. Provider business mailing address

1900 W KEM RD
MARION IN
46952-1548
US

V. Phone/Fax

Practice location:
  • Phone: 765-664-0107
  • Fax: 765-664-6541
Mailing address:
  • Phone: 765-664-0107
  • Fax: 765-664-6541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number07000307
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000307
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000000083983
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerBLUE CROSS BLUE SHIELD
# 2
Identifier351433975
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerTRICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: