Healthcare Provider Details

I. General information

NPI: 1932102837
Provider Name (Legal Business Name): PHILIP H IRELAND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 E 136TH ST STE 200
FISHERS IN
46037-9478
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 130 PROVIDER ENROLLMENT
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-688-5980
  • Fax: 317-678-3222
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number01025374A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: