Basic Information
| Provider Information | |||||||||
| NPI: | 1942374517 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERIPATH INDIANAPOLIS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328018 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 2560 N SHADELAND AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462191706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172758000 | ||||||||
| FaxNumber: | 3172758124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOLAN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6686978378 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 15D1052105 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000104995 | 01 | IN | ANTHEM | OTHER | 200168060A | 05 | IN | MEDICAID | CI4095 | 01 | IN | RAILROAD MEDICARE | OTHER | 7100137960 | 05 | KY | MEDICAID |