Basic Information
| Provider Information | |||||||||
| NPI: | 1083797781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOUSE | ||||||||
| FirstName: | BRET | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10995 ALLISONVILLE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460382617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178427928 | ||||||||
| FaxNumber: | 3178413337 | ||||||||
| Practice Location | |||||||||
| Address1: | 10995 ALLISONVILLE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460382617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178427928 | ||||||||
| FaxNumber: | 3178413337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 10/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01042875 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200086320 | 05 | IN | MEDICAID |