=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295934784
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICK J. SHEETS, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2007
-----------------------------------------------------
Last Update Date | 10/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9301 CONNECTICUT DRIVE
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-756-2100
-----------------------------------------------------
Fax | 219-756-0423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9301 CONNECTICUT DRIVE
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-1459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-756-2100
-----------------------------------------------------
Fax | 219-756-0423
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. HANAAN R. ANSARI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 219-796-4120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01054176A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------