Provider Demographics
NPI:1366518102
Name:WAYNE COUNTY AUDITOR
Entity type:Organization
Organization Name:WAYNE COUNTY AUDITOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-973-9294
Mailing Address - Street 1:203 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-4208
Mailing Address - Country:US
Mailing Address - Phone:765-973-9294
Mailing Address - Fax:765-973-9233
Practice Address - Street 1:203 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-4208
Practice Address - Country:US
Practice Address - Phone:765-973-9294
Practice Address - Fax:765-973-9233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
IN261QR1300X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200971700Medicaid
IN100257290Medicaid
IN905170Medicare ID - Type Unspecified
IN15-1964Medicare PIN
IN153895Medicare PIN