Basic Information
| Provider Information | |||||||||
| NPI: | 1396879292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYNN | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | WADE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217468 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7150 CLEARVISTA DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462561695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176215890 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 01037887A | IN | N | Allopathic & Osteopathic Physicians | General Practice | 208000000X | 01037887 | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100356530 | 05 | IN | MEDICAID | P01456893 | 01 | IN | MEDICARE RAILROAD PTAN | OTHER |