Basic Information
| Provider Information | |||||||||
| NPI: | 1104032671 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA HEART HOSPITAL LLC | ||||||||
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| OtherOrganizationName: | COMMUNITY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E. 75TH STREET | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502894 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8075 N SHADELAND AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176219312 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | MILLARD | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3176219312 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207XP3100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200861380 | 05 | IN | MEDICAID | 201033120 | 05 | IN | MEDICAID | 000000525347 | 01 | IN | ANTHEM | OTHER |