Basic Information
| Provider Information | |||||||||
| NPI: | 1619473360 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OURHEALTH PHYSICIAN GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 W MARKET ST STE 2900 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462042964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664343255 | ||||||||
| FaxNumber: | 8664220915 | ||||||||
| Practice Location | |||||||||
| Address1: | 12734 PARKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460384270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664343255 | ||||||||
| FaxNumber: | 8446756719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2018 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | IMPLEMENTATION MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3175590970 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OURHEALTH PHYSICIAN GROUP, LLC | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.