Basic Information
| Provider Information | |||||||||
| NPI: | 1538262795 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA CENTER FOR PRENATAL DIAGNOSIS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68952 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462680952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178023119 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 6845 RAMA DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462191707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178466775 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 03/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | LENKE | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3178466775 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200889210 | 05 | IN | MEDICAID |