MEDICARE: INDIANA MICRO HOSPITAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0002X	Clinic Pharmacy

General Provider Information

NPI Number	:	1063948206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA MICRO HOSPITAL, LLC

Provider Business Mailing Address
First Line	:	1415 LOUISIANA ST FL 27
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77002-7360
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9460 E 146TH ST
Second Line	:
City	:	NOBLESVILLE
State	:	IN
Zip	:	46060-4966
Country	:	US
Telephone Number	:	317-703-1999
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVEN GRAUBART
Credential	:
Telephone Number	:	713-202-3831

Provider Enumeration Date	:	05/09/2017
Last Update Date	:	05/09/2017

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