Healthcare Provider Details

I. General information

NPI: 1710951165
Provider Name (Legal Business Name): NORTHSIDE DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9865 E 116TH ST STE 200
FISHERS IN
46037-9238
US

IV. Provider business mailing address

9865 E 116TH ST SUITE 200
FISHERS IN
46037-9238
US

V. Phone/Fax

Practice location:
  • Phone: 317-849-6600
  • Fax: 317-849-6601
Mailing address:
  • Phone: 317-849-6600
  • Fax: 317-849-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number01055268A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE KUHN
Title or Position: PHYSICIAN/MANAGING MEMBER
Credential: M.D.
Phone: 317-849-6600