Unknown Individual – Surgery Physician, NPI 1194820704

Surgery Physician

Unknown Individual is a healthcare provider. based in Washington, Indiana. specializing in Surgery Physician. They hold a License No. 02003906B (IN). The NPI Number for Unknown Individual is 1194820704

Main info

Organization

Inactive

34 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1194820704

Phone

(812) 254-7310

Address

1402 GRAND AVE

Deactivation Date

24 April 2024

Doctor Profile

Medical School Name

PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE

Secondary Phone

5755442030

Graduation Year

1992 (34 years ago)

PAC ID

1254502339

Group Practice PAC ID

8325001548

Professional Enrollment ID

I20170511002714

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

Provider Addresses for Unknown Individual

1402, Grand Avenue, Northwest Everett, Everett, Snohomish County, Washington, 98201, United States
WASHINGTON, IN 475012122
Phone: (812) 254-7310
Fax: (812) 257-8602
Type: Mailing
1900 Hot Springs Blvd Ste A
Las Vegas, NM 877013480
Phone: (505) 426-3795
Type: Location
1900 HOT SPRINGS BLVD STE A
LAS VEGAS, NM 877013480
Phone: (505) 426-3795
Fax: (505) 750-9017
Type: Mailing

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

Loading prescription activity...

Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

Top Medicare procedures (2023) · refreshed 2026-05-27

HCPCS	Description	Services	Beneficiaries	Medicare allowed
99213	Established patient office or other outpatient visit, 20-29 minutes	33	27	$0
99203	New patient office or other outpatient visit, 30-44 minutes	26	26	$0

View full utilization report →

Insurance plans in this area (ZIP 47501)

Loading plans...

Provider's Procedures

Unknown Individual performs procedures in Surgery Physician. See the list of HCPCS codes below.

Specialty	Practice State	HCPCS Code	Description	Service Count	Beneficiary Count
GENERAL SURGERY	IN	11042	Removal of skin and tissue first 20 sq cm or less	172	44

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 8325001548View full group profile

Name	Specialty	State
ANGELA EDWARDS (D.P.M)	P O D I A T R Y	NM
MR. GENS PIERCE GOODMAN (D.O.)	Orthopedic Surgery	TX
DR. MITAL SUMANKUMAR PATEL (M.D. (ORTHOPAEDICS))	Orthopedic Surgery	WA
DR. ADAM BEVEVINO (M.D.)	Orthopedic Surgery	AZ
DR. SREENIVASA REDDY ALLA (M.D.)	Orthopedic Surgery	KY
AMY ELIZABETH MARTIN (M.D.)	General Surgery	AZ