Basic Information
| Provider Information | |||||||||
| NPI: | 1801899901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | SUZETTE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 TOWN CENTER RD S | ||||||||
| Address2: | STE B | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461582321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174972300 | ||||||||
| FaxNumber: | 3174972502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01040509A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000000283023 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 200130700 | 05 | IN | MEDICAID | P01018478 | 01 | IN | RR MEDICARE | OTHER |