Basic Information
| Provider Information | |||||||||
| NPI: | 1578205548 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA HOME BASED PRIMARY CARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 N WHITTINGTON PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402227101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026307425 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11550 N MERIDIAN ST STE 375-A | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460326956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4632235702 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2022 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | MATTINGLY | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5026307425 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | N | Agencies | In Home Supportive Care | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.