Basic Information
| Provider Information | |||||||||
| NPI: | 1609239169 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERICAN HEALTH NETWORK OF INDIANA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MPI HEALTH CONNECTIONS LOGAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10333 N MERIDIAN ST | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462901150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175823937 | ||||||||
| FaxNumber: | 3175823937 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 E DEWEY ST | ||||||||
| Address2: | |||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469474933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747378634 | ||||||||
| FaxNumber: | 5742174825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2016 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF AHN | ||||||||
| AuthorizedOfficialTelephone: | 3175806303 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 71000987B | IN | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QP2300X | 01065108A | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.