Healthcare Provider Details

I. General information

NPI: 1982155487
Provider Name (Legal Business Name): BEACON PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10967 ALLISONVILLE RD STE 110
FISHERS IN
46038-2634
US

IV. Provider business mailing address

10967 ALLISONVILLE RD STE 110
FISHERS IN
46038-2634
US

V. Phone/Fax

Practice location:
  • Phone: 317-599-5970
  • Fax:
Mailing address:
  • Phone: 317-559-5970
  • Fax: 317-559-7971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER DONALD FARR
Title or Position: OWNER
Credential:
Phone: 317-559-7970