Basic Information
| Provider Information | |||||||||
| NPI: | 1629078316 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METHODIST UROLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 N SENATE BLVD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179623700 | ||||||||
| FaxNumber: | 3179628800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 N SENATE BLVD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179623700 | ||||||||
| FaxNumber: | 3179628800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAMP | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3179628205 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200218250A | 05 | IN | MEDICAID |