Basic Information
| Provider Information | |||||||||
| NPI: | 1659662419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTRZEBOWSKI | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217588 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1675 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAPEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460519671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655343127 | ||||||||
| FaxNumber: | 7655343022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2011 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 02004072A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201133760 | 05 | IN | MEDICAID | P01424393 | 01 | IN | RR MEDICARE | OTHER |