Basic Information
| Provider Information | |||||||||
| NPI: | 1528666922 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARECONNECTMD MEDICAL GROUP INDIANA PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 16162 BEACH BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926473828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887899585 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9465 COUNSELORS ROW STE 200 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462403817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6572025944 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2020 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FIELDS | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7145524123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Corporate Health |
No ID Information.