Basic Information
| Provider Information | |||||||||
| NPI: | 1760432397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSIC | ||||||||
| FirstName: | MARYELLEN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N MERIDIAN STREET | ||||||||
| Address2: | SUITE 500 - PROVIDER ENROLLMENT | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462043908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179630595 | ||||||||
| FaxNumber: | 3179624950 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 RILEY HOSPITAL DR | ||||||||
| Address2: | SUITE 1300 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179442801 | ||||||||
| FaxNumber: | 3179445630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD053599L | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 01069711A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0014850040010 | 05 | PA | MEDICAID | 201055470 | 05 | IN | MEDICAID |