Healthcare Provider Details

I. General information

NPI: 1871576843
Provider Name (Legal Business Name): COLLEEN CATHERINE ROOT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12708 E 116TH ST
FISHERS IN
46037-7600
US

IV. Provider business mailing address

10330 N MERIDIAN ST SUITE 201
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 317-415-5800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01050931A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: