Healthcare Provider Details

I. General information

NPI: 1467459750
Provider Name (Legal Business Name): MARK R MCMURTREY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11161 RANDOLPH ST
CROWN POINT IN
46307-8564
US

IV. Provider business mailing address

1040 SIERRA DR SUITE 400
GREENWOOD IN
46143-7241
US

V. Phone/Fax

Practice location:
  • Phone: 219-662-9424
  • Fax: 219-662-7465
Mailing address:
  • Phone: 317-528-4284
  • Fax: 317-865-8355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01053168
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: