1154405645 NPI number — BRENDAN LEROY MD

Table of content: BRENDAN LEROY MD (NPI 1154405645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154405645 NPI number — BRENDAN LEROY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEROY
Provider First Name:
BRENDAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154405645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6626 E 75TH ST
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
545 VITALITY DR STE 100A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORTVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-621-9220
Provider Business Practice Location Address Fax Number:
317-621-9222
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01062433 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01390900 . This is a "MEDICARE RR PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200830820 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000000566825 . This is a "INDIANA BCBS/ANTHEM HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9814091 . This is a "AETNA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".




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