Basic Information
| Provider Information | |||||||||
| NPI: | 1649508466 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA CLINIC - UROLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N MERIDIAN ST | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462043908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179624942 | ||||||||
| FaxNumber: | 3179624950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 N SENATE BLVD | ||||||||
| Address2: | STE 220 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179623700 | ||||||||
| FaxNumber: | 3179628800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2009 | ||||||||
| LastUpdateDate: | 09/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | KARP | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3172783522 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INDIANA UNIVERSITY HEALTH CARE ASSOCIATES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200984020 | 05 | IN | MEDICAID |