Basic Information
Provider Information | |||||||||
NPI: | 1003871690 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRINCE | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | I. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8805 N MERIDIAN ST | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462602760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177067246 | ||||||||
FaxNumber: | 3177063419 | ||||||||
Practice Location | |||||||||
Address1: | 533 E COUNTY LINE RD | ||||||||
Address2: | SUITE 201 | ||||||||
City: | GREENWOOD | ||||||||
State: | IN | ||||||||
PostalCode: | 461431073 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177067246 | ||||||||
FaxNumber: | 3177063419 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2006 | ||||||||
LastUpdateDate: | 02/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 0101234699 | VA | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207LP2900X | 01068883A | IN | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 010209919 | 05 | VA |   | MEDICAID | 200999780 | 05 | IN |   | MEDICAID | 504240 | 01 | IL | MEDICARE GROUP # | OTHER |