Basic Information
Provider Information | |||||||||
NPI: | 1003212655 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMERICAN HEALTH NETWORK OF INDIANA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10689 N PENNSYLVANIA ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462801070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175806307 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2355 ENDRESS PLACE ST A | ||||||||
Address2: | HEALTHY MEASURES WELLNESS CLINIC | ||||||||
City: | GREENWOOD | ||||||||
State: | IN | ||||||||
PostalCode: | 46143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175301811 | ||||||||
FaxNumber: | 3175351449 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2014 | ||||||||
LastUpdateDate: | 11/10/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PARK | ||||||||
AuthorizedOfficialFirstName: | BEN | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 3175806314 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | AMERICAN HEALTH NETWORK OF INDIANA, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X |   | IN | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
No ID Information.