Basic Information
| Provider Information | |||||||||
| NPI: | 1215383021 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRACTICE SERVICES OF INDIANA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 N RACINE AVE | ||||||||
| Address2: | 100 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606071644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 3128668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 6401 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462196614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 3128668014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2016 | ||||||||
| LastUpdateDate: | 05/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | GRIFFIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3126008484 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OAK STREET HEALTH MSO LLC | ||||||||
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| AuthorizedOfficialCredential: | M.D., M.B.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.