1376975854 NPI number — CARRIE GRAVES NP

Table of content: CARRIE GRAVES NP (NPI 1376975854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376975854 NPI number — CARRIE GRAVES NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAVES
Provider First Name:
CARRIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1376975854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2024
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:
STE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2890
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:
1550 E COUNTY LINE RD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46227-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-497-2130
Provider Business Practice Location Address Fax Number:
317-863-2198
Provider Enumeration Date:
08/06/2013

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: 163WR0006X , with the licence number:  28156443A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 71005978A , 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: P01588221 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201338770 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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