Basic Information
| Provider Information | |||||||||
| NPI: | 1316354368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERICAN HEALTH NETWORK OF INDIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10689 N PENNSYLVANIA ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462801070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175806307 | ||||||||
| FaxNumber: | 3175806307 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 MANCHESTER AVE STE B | ||||||||
| Address2: | FORD METER BOX - SUPERIOR HEALTH | ||||||||
| City: | WABASH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469921420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2605693757 | ||||||||
| FaxNumber: | 2605693586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2014 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3175806314 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERICAN HEALTH NETWORK OF INDIANA, LLC | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 01031965A | IN | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.