Basic Information
| Provider Information | |||||||||
| NPI: | 1841291622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILBERG | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7301 E 90TH ST | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462567206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175651411 | ||||||||
| FaxNumber: | 3178418253 | ||||||||
| Practice Location | |||||||||
| Address1: | 7430 N SHADELAND AVE | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178417990 | ||||||||
| FaxNumber: | 3178418253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 07000964A | IN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 200441830A | 05 | IN | MEDICAID |