=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225554801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALPINE PHYSICIANS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2017
-----------------------------------------------------
Last Update Date | 06/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3660 ROME DR
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47905-4488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-446-9394
-----------------------------------------------------
Fax | 765-447-8875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 HAZEL LN STE 305
-----------------------------------------------------
City | SEWICKLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15143-1249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-588-3546
-----------------------------------------------------
Fax | 412-710-7068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP PHYS SERVICES
-----------------------------------------------------
Name | MRS. COLLEEN BRENNAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-588-3546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------