Healthcare Provider Details

I. General information

NPI: 1245501980
Provider Name (Legal Business Name): CENTRAL INDIANA ORTHOPEDICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 ENTERPRISE DR
ANDERSON IN
46013-9684
US

IV. Provider business mailing address

3600 W BETHEL AVE
MUNCIE IN
47304-5407
US

V. Phone/Fax

Practice location:
  • Phone: 765-683-4400
  • Fax: 765-608-3657
Mailing address:
  • Phone: 765-683-4400
  • Fax: 765-608-3657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000811A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: VICTOR P MORAN
Title or Position: CEO
Credential:
Phone: 765-284-7738