Basic Information
Provider Information
NPI: 1639109945
EntityType: 2
ReplacementNPI:  
OrganizationName: EMERGENCY MEDICINE PROFESSIONALS OF INDIANA LLC
LastName:  
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Mailing Information
Address1: PO BOX 1204
Address2:  
City: INDIANAPOLIS
State: IN
PostalCode: 462061204
CountryCode: US
TelephoneNumber: 3178023160
FaxNumber: 3178700499
Practice Location
Address1: 4011 SO MONROE MEDICAL PARK BLVD
Address2:  
City: BLOOMINGTON
State: IN
PostalCode: 474039765
CountryCode: US
TelephoneNumber: 8128245700
FaxNumber: 8128250766
Other Information
ProviderEnumerationDate: 07/03/2006
LastUpdateDate: 06/13/2011
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: MANSHIP
AuthorizedOfficialFirstName: MARK
AuthorizedOfficialMiddleName: E
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 3178700480
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207P00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansEmergency Medicine 

ID Information
IDTypeStateIssuerDescription
200828620A05IN MEDICAID


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