Basic Information
| Provider Information | |||||||||
| NPI: | 1588724199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'NEIL | ||||||||
| FirstName: | BERT | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7979 N SHADELAND AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176214300 | ||||||||
| FaxNumber: | 3176214301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 200101108 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 01073106A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 201183410 | 05 | IN | MEDICAID | P01339697 | 01 | IN | RAILROAD MEDICARE | OTHER | 200101108 | 01 | NC | NORTH CAROLINA MEDICAL BOARD LICENSE NUMBER | OTHER | 89129WU | 05 | NC | MEDICAID |