Basic Information
| Provider Information | |||||||||
| NPI: | 1881061059 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINDROSE HEALTH NETWORK, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WINDROSE HEALTH NETWORK-EPLER PARKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 TRAFALGAR SQ | ||||||||
| Address2: | |||||||||
| City: | TRAFALGAR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461819515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177394895 | ||||||||
| FaxNumber: | 3178782355 | ||||||||
| Practice Location | |||||||||
| Address1: | 5550 S EAST ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462271979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175344660 | ||||||||
| FaxNumber: | 3178888419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2015 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROLLETT | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3177394895 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINDROSE HEALTH NETWORK, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 151957 | 01 | IN | MEDICARE FQHC | OTHER | 200127470F | 05 | IN | MEDICAID |