Basic Information
| Provider Information | |||||||||
| NPI: | 1316273691 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ICEM-BALL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N MERIDIAN ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462041077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179621775 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657473241 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2009 | ||||||||
| LastUpdateDate: | 03/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | KARP | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3172789909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200977750A | 05 | IN | MEDICAID | DQ3173 | 01 | IN | RAILROAD MEDICARE | OTHER |