Basic Information
| Provider Information | |||||||||
| NPI: | 1578868220 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIANA PHYSICIAN MANAGEMENT-CLAY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3946 SOLUTIONS CTR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606773009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178023113 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1206 E NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | BRAZIL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478342718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178023113 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2011 | ||||||||
| LastUpdateDate: | 06/10/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BICK | ||||||||
| AuthorizedOfficialFirstName: | STEWART | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3173385053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201012070 | 05 | IN | MEDICAID |