Basic Information
Provider Information | |||||||||
NPI: | 1396162749 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANDERBUSH | ||||||||
FirstName: | BROCK | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 250 N SHADELAND AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462194959 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179623834 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4880 CENTURY PLAZA RD STE 265 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462545471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3172162700 | ||||||||
FaxNumber: | 3172162777 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2014 | ||||||||
LastUpdateDate: | 03/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01082307A | IN | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 82220 | GA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207QS0010X | 01082307A | IN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.