Basic Information
| Provider Information | |||||||||
| NPI: | 1740431576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA PHYSICIAN MANAGEMENT-NORTHEAST, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4685 RELIABLE PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178706716 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 13861 OLIO RD | ||||||||
| Address2: | |||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460373487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178706716 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | BICK | ||||||||
| AuthorizedOfficialFirstName: | STEWART | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3178706716 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 200924740 | 05 | IN | MEDICAID |