Basic Information
| Provider Information | |||||||||
| NPI: | 1225504418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OURHEALTH PHYSICIAN GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4151 E 96TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462401442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664343255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 402 W WASHINGTON ST RM W041 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462042763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664343255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2018 | ||||||||
| LastUpdateDate: | 10/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JARED | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | EMR CLINICAL ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 3172949682 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OURHEALTH PHYSICIAN GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.