Basic Information
| Provider Information | |||||||||
| NPI: | 1376758524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEDELOW | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 514 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123533719 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | 01069197A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 2085N0904X | 4301089258 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | MD026741 | LA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 4301089258 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 35.122017 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 01069197A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1049913 | 05 | LA | MEDICAID | 04377066 | 05 | MS | MEDICAID | 201015030 | 05 | IN | MEDICAID | P01119545 | 01 | IN | RAILROAD MEDICARE | OTHER | 5186380 | 05 | MI | MEDICAID | 0090190 | 05 | OH | MEDICAID |