Basic Information
| Provider Information | |||||||||
| NPI: | 1861447211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAFAYETTE EMERGENCY CARE, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INDIANA EMERGENCY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3652 ROME DR | ||||||||
| Address2: | STE A | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654460170 | ||||||||
| FaxNumber: | 7654469279 | ||||||||
| Practice Location | |||||||||
| Address1: | 5165 MCCARTY LN | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479058764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658385100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 11/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | O'BRIEN | ||||||||
| AuthorizedOfficialFirstName: | ERIKA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO-CFO | ||||||||
| AuthorizedOfficialTelephone: | 7654460170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 000 | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100464230 | 05 | IN | MEDICAID |