Basic Information
Provider Information | |||||||||
NPI: | 1154699346 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WINDROSE HEALTH NETWORK, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WINDROSE HEALTH NETWORK - COUNTYLINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14 TRAFALGAR SQ | ||||||||
Address2: |   | ||||||||
City: | TRAFALGAR | ||||||||
State: | IN | ||||||||
PostalCode: | 461819515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177394895 | ||||||||
FaxNumber: | 3178782355 | ||||||||
Practice Location | |||||||||
Address1: | 8921 SOUTHPOINTE DR | ||||||||
Address2: | SUITE A1 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462271084 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178847820 | ||||||||
FaxNumber: | 3178888851 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2011 | ||||||||
LastUpdateDate: | 10/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROLLETT | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | CFO / COO | ||||||||
AuthorizedOfficialTelephone: | 3177394895 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 200127470E | 05 | IN |   | MEDICAID |