Provider Demographics
NPI:1871794826
Name:TRUSTEES OF PURDUE UNIVERSITY
Entity type:Organization
Organization Name:TRUSTEES OF PURDUE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-564-3016
Mailing Address - Street 1:PO BOX 597
Mailing Address - Street 2:
Mailing Address - City:DELPHI
Mailing Address - State:IN
Mailing Address - Zip Code:46923-0597
Mailing Address - Country:US
Mailing Address - Phone:765-564-3016
Mailing Address - Fax:765-564-2608
Practice Address - Street 1:692 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONON
Practice Address - State:IN
Practice Address - Zip Code:47959-8191
Practice Address - Country:US
Practice Address - Phone:877-797-2404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PURDUE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-29
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200852780AMedicaid
15-1862Medicare PIN