1184625436 NPI number — INDIANA PEDIATRIC OPHTHALMOLOGY & ADULT STRABISMUS, LLC

Table of content: (NPI 1184625436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184625436 NPI number — INDIANA PEDIATRIC OPHTHALMOLOGY & ADULT STRABISMUS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA PEDIATRIC OPHTHALMOLOGY & ADULT STRABISMUS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1184625436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160 W MICHIGAN ST
Provider Second Line Business Mailing Address:
SUITE 217
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46202-5209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-274-1214
Provider Business Mailing Address Fax Number:
317-274-2277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 RILEY HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 3340
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-944-8103
Provider Business Practice Location Address Fax Number:
317-944-1111
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PLAGER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
317-274-1214

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , 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: 100058250 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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