Basic Information
| Provider Information | |||||||||
| NPI: | 1316919079 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERIPATH INDIANAPOLIS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 2560 N SHADELAND AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462191706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172758005 | ||||||||
| FaxNumber: | 3172758018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOLAN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8666978378 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 291U00000X | 15D1002565 | IN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 200168060A | 05 | IN | MEDICAID | 1316919079 | 05 | MI | MEDICAID | 1316919079 | 05 | MN | MEDICAID | 7100184740 | 05 | KY | MEDICAID | 2884188 | 05 | OH | MEDICAID | 7100063140 | 05 | KY | MEDICAID |