Basic Information
| Provider Information | |||||||||
| NPI: | 1154327633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACKERMAN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7120 CLEARVISTA DR | ||||||||
| Address2: | STE 2100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462561621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176215676 | ||||||||
| FaxNumber: | 3176215678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01043845A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 01043845 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01214624 | 01 | IN | RR MEDICARE PTAN | OTHER | 200068200A | 05 | IN | MEDICAID |